sign in sign up
<<
Home , Blepharitis, Onchocerciasis

Community Eye Health

JOURNALVOLUME 29 | ISSUE 95 | 2016 Ocular surface disorders

EDITORIAL Assessment and diagnosis: a rational approach Jeremy Hoffman Academic Clinical Fellow: International Centre for Eye Health and Specialist Registrar, Moorfields Eye Hospital, London, UK. Matthew Burton Professor: International Centre for Eye Health and Consultant Ophthalmologist: Moorfields Eye Hospital, London, UK. The ocular surface is critical to the health Examining the of the eye and essential for good visual ocular surface. functioning. It is a complex, integrated CAMBODIA system involving the , , tear film, lacrimal gland, nasolacrimal system and the (incorporating the meibomian glands and lashes). The normal physiological function of the ocular

surface depends on the interaction of these Sight Day Photo Competition www.flickr.com/photos/iapb Sophiavid Choum, World different components. Working together, they maintain a clear optical surface, symptoms and signs, taking a detailed ) keep the eye from drying out, and protect it history is very important. Ask patients • Purulent discharge from trauma and . Changes in the whether they have experienced, or are • Watering, whether from lacrimation structure and function of any of the ocular experiencing, any of the following: (increased tear production) or surface components can disrupt its delicate • Reduced vision (mild blurring can (decreased tear drainage) balance and lead to pathology. occur if the tear film is disturbed; It is important to take a careful note of Ocular surface diseases have a a more severe visual disturbance when and how the problem developed. relatively limited set of symptoms and suggests corneal or other disease) You need to ask if there has been a history signs, and a systematic approach to • Redness of trauma or a foreign body. In some assessing and diagnosing these conditions • Irritation or gritty sensation settings, contact use is common and is therefore necessary. (suggests epithelial disturbance) you need to ask about this. If patients do • Itching (suggests ) use contact lenses, ask how they clean History • Pain (sharp pain suggests a corneal and use them. Because patients with ocular surface problem or foreign body; a duller problems present with a limited range of ache may suggest uveal or scleral Examination Your examination of the ocular surface ABOUT THIS ISSUE needs to be systematic. A stepwise Many diseases can affect the ocular surface. Their frequency and severity varies approach helps to ensure that important from region to region, often depending on the local climate. Ocular surface diseases things are not missed. can affect both eyesight and quality of life, and ­– in severe cases – cause blindness. Because they have a limited number of symptoms and signs, and can appear very • Vision. Start by assessing the similar in presentation, patients can be misdiagnosed and hence poorly managed. uncorrected, pinhole and best corrected In this issue, we offer a systematic approach to assessing and diagnosing common visual acuity. ocular surface diseases and look in detail at general management principles, • Eyelids. Examine the lid position including how to control inflammation. Other articles discuss ocular allergy, and closure and check for and squamous cell carcinoma. In the middle of the issue we also have a (when the turns in on itself), poster with useful information about common ocular surface conditions and their (lashes touching the eye) primary management. — Elmien Wolvaardt Ellison (Editor) and (a gap between Continues overleaf ➤

COMMUNITY EYE HEALTH JOURNAL | VOLUME 29 ISSUE 95 | 2016 41 EDITORIAL Continued

the upper and lower lid when the eyes the eye’s surface shiny (healthy), or 41 Assessment and diagnosis: are closed). Examine the lid margin rough and/or dull? Also test for corneal a rational approach and openings for sensation, which may be reduced due to abnormal positions, inflammation and infection with or zoster. 44 Managing ocular surface plugging with secretions. Try to express • Corneal stroma. Look for stromal disease: a common-sense the meibomian glands, using gentle opacities. Assess the size, location, approach pressure. pattern and depth. Opacities may be • . Assess the quality of the tear scars or active inflammatory infiltrates. 47 Managing ocular allergy in film by looking for discharge or debris Look for blood vessels: active vessels resource-poor settings and the tear meniscus height (to give have blood flowing, inactive have a 50 POSTER an idea of quantity). Check the tear clear, grey outline without blood. Common and important ocular break-up time by instilling a drop of • Corneal endothelium. Look for any surface conditions and timing how long it takes guttata, Descemet folds and the for the tear film to disperse. A tear presence and type of any deposits 52 Squamous cell carcinoma break-up time of less than 10 seconds (blood, keratic precipitates or pigment). of the conjunctiva is abnormal. Finally, perform Schirmer’s test by placing a testing strip in the Diagnosis 54 Understanding and inferior conjunctival fornix and asking Problems affecting the ocular surface managing pterygium the patient to close their eyes for five broadly divide into non-infectious and minutes. A normal result is >15 mm. infectious conditions. They present with a 56 CLINICAL SKILLS FOR Less than this suggests insufficient tear limited range of symptoms. The pattern of production, to varying degrees: mild is symptoms can often help to differentiate How to irrigate the eye 9–14 mm, moderate is 4–8 mm and between conditions. In Table 1 we outline 57 EQUIPMENT AND MAINTENANCE severe is <4 mm. the typical symptom pattern for some of Understanding and caring for • Bulbar conjunctiva and . the commoner conditions. For example, an indirect ophthalmoscope Assess inflammation, scarring, if the person mainly complains of itching, haemorrhages and abnormal swellings then allergic needs to be 58 UPDATE such as , pterygium or considered as a possible cause. possible malignancies. The symptoms of these different 59 CPD QUIZ • Tarsal conjunctiva. Evert the upper conditions can overlap. Therefore, a 59 PICTURE QUIZ and lower lids. Look for scarring, careful examination is critical to reaching foreign body defects, inflammatory an accurate diagnosis. Although not 60 NEWS AND NOTICES membranes, papillae and follicles. exhaustive, there is a list of common and • Corneal epithelium. Using a torch, look important ocular surface conditions on 60 USEFUL RESOURCES for foreign bodies, infiltrates, oedema pages 50–51, detailing their presenting and deposits. Is the light reflected off features and some example photographs.

Community Eye Health Editor Editorial assistant Anita Shah Correspondence articles Elmien Wolvaardt Design Lance Bellers We accept submissions of 800 words about

JOURNALVOLUME 29 | ISSUE 95 | 2016 [email protected] Printing Newman Thomson readers’ experiences. Contact: Ocular surface disorders EDITORIAL Anita Shah: [email protected] Assessment and diagnosis: a rational approach Editorial committee CEHJ online Jeremy Hoffman Academic Clinical Fellow: International Centre for Eye Health and Specialist Registrar, Moorfields Eye Hospital, London, UK. Visit the Community Eye Health Journal online. Matthew Burton Allen Foster Published by the International Centre for Eye Health, Professor: International Centre for Eye Health and Consultant Ophthalmologist: Moorfields Eye Hospital, London, UK. The ocular surface is critical to the health All back issues are available as HTML and PDF. Examining the of the eye and essential for good visual Clare Gilbert London School of Hygiene & Tropical Medicine ocular surface. functioning. It is a complex, integrated CAMBODIA system involving the cornea, conjunctiva, tear film, lacrimal gland, nasolacrimal system and the eyelids (incorporating Visit: www.cehjournal.org the meibomian glands and lashes). The Nick Astbury normal physiological function of the ocular

surface depends on the interaction of these Sight Day Photo Competition www.flickr.com/photos/iapb Sophiavid Choum, World Unless otherwise stated, authors share copyright for different components. Working together, they maintain a clear optical surface, symptoms and signs, taking a detailed inflammation) keep the eye from drying out, and protect it history is very important. Ask patients • Purulent discharge from trauma and infection. Changes in the whether they have experienced, or are • Watering, whether from lacrimation Daksha Patel structure and function of any of the ocular experiencing, any of the following: (increased tear production) or epiphora Online edition and newsletter articles with the Community Eye Health Journal. surface components can disrupt its delicate • Reduced vision (mild blurring can (decreased tear drainage) balance and lead to pathology. occur if the tear film is disturbed; It is important to take a careful note of Ocular surface diseases have a a more severe visual disturbance when and how the problem developed. relatively limited set of symptoms and suggests corneal or other disease) You need to ask if there has been a history signs, and a systematic approach to • Redness Richard Wormald of trauma or a foreign body. In some Sally Parsley: [email protected] Illustrators and photographers retain copyright for assessing and diagnosing these conditions • Irritation or gritty sensation settings, contact lens use is common and is therefore necessary. (suggests epithelial disturbance) you need to ask about this. If patients do • Itching (suggests allergy) use contact lenses, ask how they clean History • Pain (sharp pain suggests a corneal and use them. Because patients with ocular surface problem or foreign body; a duller Matthew Burton images published in the journal. problems present with a limited range of ache may suggest uveal or scleral Examination Your examination of the ocular surface ABOUT THIS ISSUE needs to be systematic. A stepwise Consulting editor for Issue 95 Many diseases can affect the ocular surface. Their frequency and severity varies approach helps to ensure that important from region to region, often depending on the local climate. Ocular surface diseases things are not missed. can affect both eyesight and quality of life, and – in severe cases – cause blindness. Hannah Kuper Because they have a limited number of symptoms and signs, and can appear very • Vision. Start by assessing the similar in presentation, patients can be misdiagnosed and hence poorly managed. uncorrected, pinhole and best corrected Unless otherwise stated, journal content is licensed In this issue, we offer a systematic approach to assessing and diagnosing common visual acuity. Matthew Burton and Allen Foster ocular surface diseases and look in detail at general management principles, • Eyelids. Examine the lid position including how to control inflammation. Other articles discuss ocular allergy, and closure and check for entropion (when the eyelid turns in on itself), Priya Morjaria pterygium and squamous cell carcinoma. In the middle of the issue we also have a poster with useful information about common ocular surface conditions and their trichiasis (lashes touching the eye) under a Creative Commons Attribution-NonCommercial primary management. — Elmien Wolvaardt Ellison (Editor) and lagophthalmos (a gap between Continues overleaf ➤ COMMUNITY EYE HEALTH JOURNAL | VOLUME 29 ISSUE 95 | 2016 41 G V Murthy Please support us (CC BY-NC) license which permits unrestricted use, Fatima Kyari We rely on donations/subscriptions from charities “Improving eye health through distribution, and reproduction in any medium for David Yorston and generous individuals to carry out our work. the delivery of practical non-commercial purposes, provided that the copyright Sally Crook We need your help. holders are acknowledged. high-quality information for the eye care team” Serge Resnikoff Subscriptions in high-income countries cost UK Woodcut-style graphics by Victoria Francis and Teresa Babar Qureshi £100 per annum. Dodgson. Volume 29 | ISSUE 95 Janet Marsden ISSN 0953-6833 Noela Prasad Contact Anita Shah [email protected] Supporting VISION 2020: or visit our website: www.cehjournal.org/donate The Right to Sight Regional consultants Disclaimer Subscriptions Signed articles are the responsibility of the named Hugh Taylor (WPR) authors alone and do not necessarily reflect the views Leshan Tan (WPR) Readers in low- and middle-income countries of the London School of Hygiene & Tropical Medicine GVS Murthy (SEAR) receive the journal free of charge. Send your name, occupation, and postal address to the (the School). Although every effort is made to ensure R Thulsiraj (SEAR) accuracy, the School does not warrant that the address opposite. French, Spanish, and Chinese Babar Qureshi (EMR) information contained in this publication is complete editions are available. To subscribe online, visit Mansur Rabiu (EMR) and correct and shall not be liable for any damages www.cehjournal.org/subscribe Hannah Faal (AFR) incurred as a result of its use. Kovin Naidoo (AFR) Address for subscriptions The mention of specific companies or of certain Winjiku Mathenge (AFR) Anita Shah, International Centre for Eye Health, manufacturers’ products does not imply that they are Ian Murdoch (EUR) London School of Hygiene and Tropical Medicine, endorsed or recommended by the School in preference to Janos Nemeth (EUR) Keppel Street, London WC1E 7HT, UK. others of a similar nature that are not mentioned. The School Van Lansingh (AMR) Tel +44 (0)207 958 8336 does not endorse or recommend products or services Andrea Zin (AMR) Email [email protected] for which you may view advertisements in this Journal.

42 COMMUNITY EYE HEALTH JOURNAL | VOLUME 29 ISSUE 95 | 2016 Table 1: Symptom and signs of common conditions Key: Absent Possible Present, moderate Present, severe

Condition Bacterial Viral Allergic Microbial Dry eye Mucous Stephens- Symptoms/ conjunctivitis conjunctivitis conjunctivitis membrane Johnson signs pemphigoid Syndrome

Red

Pain

Itchy

Irritation or gritty sensation Watery discharge Purulent discharge

Understanding the ocular surface Jeremy Hoffman and Matthew Burton The ocular surface consists of the cornea, Conjunctiva surface conditions, with shortened conjunctiva, tear film, lacrimal gland, The conjunctiva is composed of an fornices, symblepharon (adhesions nasolacrimal system and the eyelids epithelial layer overlaying a loose between the eye lid and ) and (incorporating the meibomian glands connective tissue (stroma). It covers distortion of the eyelids. and lashes), each of which is described the eye from the edge of the cornea Tear film in detail below. Figure 1 shows the (limbus) to the fornices and the inside The tear film is made up of three layers. anatomy of the upper eyelid and anterior surface of the eyelids. It contains The outer lipid layer (produced by the segment of the eye in cross-section. specialised goblet cells that produce meibomian glands) reduces evaporation the mucus layer of the tear film. In the Cornea of the middle aqueous layer (produced stromal layer of the conjunctiva, there The cornea is the most powerful by the lacrimal gland), with the inner are immune system cells that defend refracting component of the eye. Together mucin layer (produced by goblet cells) against infection. Sometimes lymphoid with the lens, it focuses light on the helping to stabilise the aqueous layer on cells are recruited and gather together . The central 4 mm zone is critical the corneal epithelium. A good tear film to form visible follicles, particularly on helps to maintain a well-hydrated, healthy for good vision. The cornea is made up of the tarsal conjunctival surface. Papillae, five layers: epithelium, Bowman’s layer, corneal epithelium and a clear optical which form in the tarsal conjunctiva, are surface, and it protects against infection. stroma, Descemet’s membrane and dome-like swellings with inflammatory endothelium. The normal cornea does cells, oedema and a dilated blood Lacrimal gland not have blood vessels; it gains oxygen vessel. Conjunctival scarring develops The lacrimal gland sits in the supero- and nutrients through diffusion from in some chronic inflammatory ocular lateral region of the . Fine ducts the aqueous, from limbal blood vessels open into the upper fornix, delivering and from the atmosphere. The cornea is Figure 1: Anatomy of the upper eyelid lacrimal fluid to the ocular surface. very sensitive; there is dense innervation and anterior segment of the eye in Secretion of tear fluid is controlled by fine nerve fibres from the trigeminal cross-section by the parasympathetic nervous nerve. Normal corneal sensation is system. Problems with the gland itself, essential for a healthy intact epithelial Lacrimal obstruction of the ducts (by scarring) surface, tear function and protection gland and neurological problems can all result through the blink reflex. in reduced aqueous tear production. If damaged, the corneal epithelium can regenerate, so simple abrasion Nasolacrimal system injuries can heal without scarring. Meibomian The nasolacrimal system drains tear Upper fluid from the surface of the eye. Fluid However, if the stem cells that repopulate gland fornix is collected through the punctae and the corneal epithelial surface are passes along the canaliculi into the damaged, for example by a chemical lacrimal sac. From the sac, the fluid injury, the resulting epithelium is passes down the nasolacrimal duct and abnormal and clarity is lost. Corneal Tear film drains into the nasal cavity. Obstruction clarity also depends on there being a Cornea at any point along the system can highly ordered arrangement of collagen Bulbar Limbus result in a watery eye (epiphora) and fibres within the stroma. These deeper conjunctiva predispose the eye to infection. layers are unable to regenerate well and often heal with scarring. In addition, Eyelids the cornea needs to be maintained in a Lower Eyelids protect the eyes by covering relatively dehydrated state by the action fornix them. They are formed of several layers: of the endothelial cell layer. If this is not Tarsal skin, the orbicularis muscle, the tarsal conjunctiva functioning well, the cornea becomes plate (including the meibomian glands),

oedematous and opaque. Mallen www.schepens.harvard.edu Peter and the conjunctiva.

© The author/s and Community Eye Health Journal 2016. This is an Open Access COMMUNITY EYE HEALTH JOURNAL | VOLUME 29 ISSUE 95 | 2016 43 article distributed under the Creative Commons Attribution Non-Commercial License. MANAGEMENT Managing ocular surface disease: a common-sense approach

Hon Shing Ong Clinical and Research Fellow: Involving patients is needed for Corneal and External Disease Service, good management of ocular Moorfields Eye Hospital, London, United surface diseases. INDIA Kingdom. [email protected] John KG Dart Professor and Consultant Ophthalmologist: Corneal and External Disease Service, Moorfields Eye Hospital, London, United Kingdom. Many diseases can cause ocular surface disorders. The poster on pages 50–51 provides an overview of the most common diseases, and other articles in this issue focus on the management of individual diseases. In this article, the authors offer a systematic strategy for the overall management of ocular surface diseases. Sight Day Photo Competition www.flickr.com/photos/iapb World When managing patients with an ocular surface condition, identifying the underlying disease is valuable (see T Murugesan, pages 41–43 for guidance on assessment Ocular surface irritants have a negative (e.g. trichiasis, entropion) must be and diagnosis). However, diagnosis can effect on the recovery of the ocular promptly addressed. Where appropriate, sometimes be difficult or even impos- 1 sible, as complex interactions exist surface. A common example is the use eyelid should be considered. of drops on a continuous basis. between the different components of the 2 Support ocular lubrication ocular surface. A wide range of conditions Unnecessary topical should be discontinued or systemic alternatives An overlying physiological tear fluid is can therefore result in similar functional essential for a healthy ocular surface.3 effects at the ocular surface. These sought. If drops are needed, preserv- ative-free formulations should be used Supporting the tear film should be functional effects manifest as clinical considered in all cases of ocular surface where possible, especially if more than signs common to several diseases, and disease, especially if the eye is dry. six drops are required daily. It may also include chronic punctate keratopathy, Lubricants not only serve as tear substi- be advisable to avoid using make-up and filamentary keratopathy, recurrent corneal tutes, they also help to dilute ocular cosmetics on the eyelids and around the erosion, bacterial conjunctivitis, culture- surface irritants and reduce the shearing eye. Removal of exacerbating factors is negative conjunctivitis, cicatrising (scarring) forces of the eyelids on the corneal particularly important in certain ocular conjunctivitis, persistent epithelial defect, epithelium. Many ocular lubricants are surface diseases, such as allergic eye infectious keratitis, corneal melt and available. Some examples include hyalu- disease and Stevens-Johnson Syndrome. ocular surface failure (Figures 1A–G). ronate, carmellose, hypromellose, Fortunately, in the absence of a definite Blepharitis is common and should polyvinyl alcohol, and paraffin. Lubricants diagnosis, ocular surface diseases can be controlled to reduce its effects on with lipids or osmoprotectants (e.g. 2 usually still be managed effectively, tear film quality and the ocular surface. glycerine and L-Carnitine) are also provided the choice of approach and Lid hygiene (lid cleaning) removes available. Excess mucous can be treated therapy is based on the functional effects crusts, debris and bacteria load on the with N-acetylcysteine drops. observed and their severity. It is therefore lid margins in anterior blepharitis. Warm Preservative-free lubricants are important to have a systematic approach compresses and lid massage mechan- preferable for treating patients with ocular to the identification of functional effects ically unblocks meibomian glands in surface disease. Excessive use of drops and their severity (see Figure 2). Many of posterior lid margin disease. One- to with preservatives that are not diluted by these functional effects are susceptible to three-month courses of tetracycline class normal tear flow can cause intolerance or a range of therapies, as discussed below. agents, such as 100 mg once ocular surface toxicity and impede ocular a day, are often helpful in controlling surface healing. Note: Ocular surface disorders often blepharitis in adults. Note: doxycy- In aqueous-deficient dry eyes, punctal affect both eyes asymmetrically. cline should not be given to children. occlusion can prevent tear drainage Where patients present with unilateral In children, or in adults where doxycy- and prolong the effects of tear substi- disease, neoplasia – e.g. ocular surface cline is not tolerated, macrolides, such tutes. Punctal occlusion may exacerbate squamous neoplasia (Figure 1H) – as erythromycin 250 mg twice a day, can symptoms of blepharitis, so this must be must be excluded. be used. They are thought to improve treated beforehand. Permanent occlusion meibomian gland dysfunction by altering can be achieved by using punctal cautery. Management their metabolism and secretion. Newer Parasympathomimetics such as oral 1 Eliminate exacerbating factors therapies, such as topical azithromycin pilocarpine can also be useful if tolerated. Eliminating exacerbating factors (if 1.5% twice a day for 3 days, repeated In more severe disease, autologous present) should be considered in all weekly for 4–8 weeks, are also available. serum is beneficial, but this is expensive patients with ocular surface disease. Diseases of the eyelid and its adnexae and not always readily available.

44 COMMUNITY EYE HEALTH JOURNAL | VOLUME 29 ISSUE 95 | 2016 Figure 1. Functional effects (clinical signs) of ocular surface disorders Figure 2. Ophthalmological assessment A B of a patient with ocular surface disease Assess facial and periocular skin, eyelids, and conjunctival inflammation in normal light (preferably daylight)

Perform a examination without eyelid manipulation to assess the lid margins and position, , punctae, tear meniscus, and tear film quality John KG Dart John KG Dart Chronic punctate keratopathy with Bacterial conjunctivitis associated filaments (Rose Bengal stain) Instil unpreserved dilute fluorescein into the tear meniscus (e.g. using a fluorescein strip C D wet with unpreserved )

Wait 1 minute and assess tear film break-up time over 10 seconds. Look for focal areas of irregularity and break-up

Assess for the presence of punctate stain John KG Dart John KG Dart on the cornea and conjunctiva, including the Cicatrising conjunctival changes Large persistent epithelial defect in a superior limbus (subepithelial fibrosis of the tarsal vascularised cornea conjunctiva and forniceal shortening) Assess the bulbar conjunctiva (for scarring, E F keratinisation, symblephara), fornices, limbus, and cornea (for focal abnormal wetting, filaments, thinning, infiltrates, keratinisation, scarring and vascularisation)

Evert the lids and assess the tarsal conjunctiva with white light and blue light for infiltrate, papillae, and follicles John KG Dart John KG Dart Microbial keratitis caused by Candida Central corneal melt species Perform Schirmer’s test for 5 minutes without anaesthesia. Test corneal sensation G with cotton-tipped bud or Cochet and Bonnet H anaesthesiometer

Press on lids and examine meibomian gland secretion

Instil lignocaine and fluorescein and use John KG Dart John KG Dart Lissamine Green (+/- Rose Bengal)* if no Ocular surface failure (conjunctivalisation, Ocular surface squamous neoplasia surface stain is found with fluorescein opacification and vascularisation of the cornea) *Rose Bengal is no longer available in some countries.

3 Consider therapeutic aqueous tear deficiency, hydrogel TCL 4 Control ocular surface contact lenses should be avoided as the risk of infection inflammation Therapeutic contact lenses (TCL) can is high. In very dry eyes, soft or silicone An inflammatory component is seen be useful in severe dry eye diseases hydrogel TCL do not work well as they in almost every form of ocular surface and persistent epithelial defects. tighten up and reduce oxygen trans- condition. Some clinical features of Proposed mechanisms of action include mission. Rigid gas-permeable scleral ocular surface inflammation include pain, modification of lid-tear-ocular surface TCL cover the cornea and most of the conjunctival injection (redness), dilatation interactions, retention of fibrin matrix conjunctiva. This can prevent excessive of conjunctival blood vessels, limbitis, on the surface of an injured cornea, and tear evaporation and protects the ocular conjunctival swelling (chemosis), redness retention of tears under rigid lenses. In surface from abnormal lids. Continues overleaf ➤

COMMUNITY EYE HEALTH JOURNAL | VOLUME 29 ISSUE 95 | 2016 45 MANAGEMENT Continued

and swelling of the eyelids (Figure 3). Figure 3. Severe ocular inflammation in ocular surface disease, namely cicatrising Ocular surface inflammation is (scarring) conjunctivitis treatable. The choice of steroids depends on the severity of inflammation. In condi- tions where there is mild ocular surface inflammation, weak topical steroids (e.g. fluorometholone, or prednisolone 0.5% preservative free) can be used on an ‘as required’ basis or as short tapering courses. In severe inflammation (e.g. acute vernal ), more

potent topical steroids (e.g. dexameth- John KG Dart John KG Dart asone 0.1%, or prednisolone 1%) are Significant conjunctival injection with Inflammation of the corneal limbus required. The frequency of drop admin- dilated vessels (limbitis) istration is titrated according to disease A conjunctival flap will sacrifice vision, but severity. In cases where prolonged steroid 5 Manage persistent corneal use is anticipated, lenticular status, epithelial defects and microbial it reduces discomfort and ocular inflam- intraocular pressure, and assessment of keratitis mation and promotes healing. If no the head must be regularly Management of persistent corneal conjunctiva is available due to scarring, a documented to monitor for side effects epithelial defects (PCED) is based on buccal mucous membrane graft can be such as and glaucoma. eliminating exacerbating factors, stimu- used to provide a stable epithelium. lating epithelialisation, improving Topical ciclosporin A (various prepara- Involve the patient tions) has been shown to be effective in epithelial stability, restoring the basement Successful management of ocular surface several ocular surface disorders without membrane, and renewing the epithelium. disorders can be difficult. Many conditions, the adverse effects of steroids. However, Nerve growth factor drops may be beneficial such as allergic eye diseases, are chronic. ciclosporin is often poorly tolerated in cases of PCED secondary to neuro- Symptoms can often be controlled but during disease exacerbations and its full trophic keratopathy. Autologous serum and efficacy is only achieved several weeks nerve growth factor treatments have both not completely eliminated. Relapse and from the initial dose. Ciclosporin has been been shown to stimulate epithelialisation. flare-ups are also common, and most shown to be better tolerated if introduced Microbial keratitis is a major compli- treatments require the involvement of the following a few weeks of treatment with cation in all patients with chronic ocular patient over a long period of time. topical steroids.4 surface disorders. In any PCED, this must be It is important that patients are Treatment of allergic excluded using appropriate microbiological counselled before any treatment is (including acute, seasonal and perennial techniques. Patients on topical steroids or started. They must understand the nature , vernal keratocon- systemic immunosuppressants may have of their condition and the expected junctivitis, and atopic keratoconjunctivitis) an infection without a corneal infiltrate. outcomes following treatment, as includes mast cell stabilisers (e.g. Where infection is suspected, empirical life-long therapies may be needed. A nedocromil, lodoxamide), antihistamines treatment with a broad-spectrum antimi- management strategy should be agreed (e.g. emedastine, loratidine, chlorphen- crobial should be initiated. Commonly, with patients and they must know how amine), or combined mast cell stabilisers/ first-line treatment would include the use of to access medical facilities in the event antihistamine (e.g. olopatadine). fluoroquinolones (e.g. moxifloxacin 0.5%, of a relapse. In severe ocular surface inflammation levofloxacin 0.5%). Where fungal infection (e.g. corneal melts, mucous membrane is suspected or diagnosed, steroid therapy Conclusion pemphigoid), rapid immunosuppression must be discontinued and appropriate Many diseases can cause ocular surface is required to prevent visual loss.5 In these anti-fungal therapy commenced. disorders. Accurate diagnosis of the situations, immunosuppressive doses underlying condition may be difficult. of steroids (e.g. prednisolone 1 mg/kg 6 Surgical management In the absence of a definite diagnosis, once a day and methylprednisolone When non-surgical therapies fail to identifying and treating the functional 500–1,000 mg intravenous daily for heal a PCED, lid closure with botulinum effects of the underlying disorder on the 1–3 days) can be started and tapered toxin injection or a temporary central ocular surface is often sufficient. off over 1–3 months once inflammation tarsorrhaphy can be used to promote is controlled. Steroid-sparing drugs (e.g. epithelial stability. In refractory PCED, References improvement of the basement membrane 1 Dart J. Corneal toxicity: the epithelium and stroma mycophenolate, azathioprine, cyclo- in iatrogenic and factitious disease. Eye. Nov phosphamide) should be started when a can be achieved through human amniotic 2003;17(8): 886-892. prolonged disease course is expected. membrane grafts, lamellar keratectomy, 2 Suzuki T, Teramukai S, Kinoshita S. Meibomian glands or lamellar keratoplasty. Small perfora- and ocular surface inflammation. The ocular surface. In ocular surface disease that is Apr 2015;13(2): 133-149. poorly controlled with topical therapy or tions can be treated with cyanoacrylate 3 Bron AJ. The Doyne Lecture. Reflections on the tears. where severe sub-acute inflammation glue and a contact lens. Therapeutic Eye. 1997;11 ( Pt 5): 583-602. lamellar or penetrating keratoplasties are 4 Sheppard JD, Donnenfeld ED, Holland EJ, et al. Effect persists, steroid-sparing therapy can be of loteprednol etabonate 0.5% on initiation of dry eye used without steroids. The use of such required for larger perforations. treatment with topical cyclosporine 0.05%. Eye & immunosuppressive agents requires Renewal of the epithelium through contact lens. Sep 2014;40(5): 289-296. 5 Saw VP, Dart JK, Rauz S, et al. Immunosuppressive specialist knowledge, monitoring, surface reconstruction can be considered therapy for ocular mucous membrane pemphigoid and facilities. These patients should if all of the above fail. Options for managing strategies and outcomes. Ophthalmology. Feb be referred to specialist clinics if local ocular surface failure due to limbal stem 2008;115(2): 253-261 e251. 6 Holland EJ, Schwartz GS. Changing concepts in the medical services have insufficient support cell deficiency include allogenic or autol- management of severe ocular surface disease over for the use of such agents. ogous limbal stem cell transplants.6 twenty-five years. Cornea. Sep 2000;19(5): 688-698.

46 COMMUNITY EYE HEALTH JOURNAL | VOLUME 29 ISSUE 95 | 2016 © The author/s and Community Eye Health Journal 2016. This is an Open Access article distributed under the Creative Commons Attribution Non-Commercial License. ALLERGIC EYE DISEASE Managing ocular allergy in resource-poor settings

Millicent Bore Signs: The hallmark sign of vernal kerato- Other ocular Lecturer: Department of conjunctivitis is papillae formation in the These include acute allergic conjunc- Ophthalmology, College of Health tarsal conjunctiva; these can be large and tivitis (seasonal and perennial allergic Sciences, University of Nairobi, Kenya. conjunctivitis) and giant papillary [email protected] irregular (known as cobblestone papillae) (Figure 2). There is conjunctival injection conjunctivitis. Predisposing factors for Ocular allergy is a common inflammatory and/or and there may giant papillary conjunctivitis include condition seen almost daily at the be peri-limbal small white dots (Horner- contact lens wear and irritation from outpatient clinic. It occurs because the Trantas dots) (Figure 3). The limbus can exposed sutures or a prosthesis. ocular surface is exposed to a variety of become pigmented and the cornea can allergens, making it susceptible to allergic NOTE: All ocular allergies can have sight- be affected with plaques and ulceration of reactions. The hallmark of the disease is threatening complications if not managed the upper cornea. itching, and the clinical symptoms and well, e.g. (due to excessive signs are bilateral and vary according to Figure 2: Papillae on the everted upper rubbing) and glaucoma (due to the individual cases. eyelid in vernal keraconjunctivitis prolonged use or misuse of steroids). The common predisposing factors of ocular allergy include environmental How do ocular allergies allergens, genetic predisposition to atopic develop? reactions and hot, dry environments. The patient may have associated The basic mechanism of these systemic features like eczema, asthma conditions is type-1 hypersensitivity. and rhinitis. The inflammatory response in vernal and atopic keraconjunctivitis is due to Types of ocular allergy inflammatory mediators, mainly from

Ocular allergies can be divided into: Jock Anderson mast cells (Figure 5). 1 Vernal keratoconjunctivitis 2 Atopic keratoconjunctivitis Figure 3. Horner-Trantas dots in a child Figure 5: The ocular allergy cascade 3 Acute allergic conjunctivitis (includes with vernal conjunctivitis in a sensitised individual seasonal and perennial allergic conjunctivitis) Exposure to sensitised 4 Giant papillary conjunctivitis allergens The first two forms of ocular allergies are sight-threatening. Both can lead to damage of the cornea by causing ulcers and scarring (secondary to inflammation of the ocular surface), ultimately leading Adherence of

to vision loss. Stefani Karakas www.eyerounds.org the allergen to the mast cell Vernal keratoconjunctivitis Figure 4. Atopic keratoconjunctivitis Onset of vernal keratoconjunctivitis is usually in childhood (mean age 7 years) and it tends to become less severe by Mast cell the late teens. It is more common in boys than in girls. If left untreated, it can result in corneal conjunctivalisation and scarring Mast cell degranulation (Figure 1). The symptoms are severe itching, watering, foreign body sensation and thick mucus discharge. John Dart Release of histamine Figure 1. Vernal keratoconjunctivitis Atopic keratoconjunctivitis and other showing injection and swelling at the limbus Atopic keratoconjunctivitis classically pre-formed mediators with conjunctivalisation of the cornea presents in adulthood and has a chronic and unremitting course. History: History of atopy (asthma, eczema). Severe itching, watering, foreign body sensation, mucus discharge. Symptoms occur year-round. Signs: Skin changes on the eyelids, e.g. Itching, redness, watering of the , dryness, scaliness and thick- eye, stringy mucoid discharge, ening. Papillae on the tarsal conjunctiva. and In severe cases, conjunctival scarring and

John Dart forniceal shortening may be present. Continues overleaf ➤

COMMUNITY EYE HEALTH JOURNAL | VOLUME 29 ISSUE 95 | 2016 47 ALLERGY Continued

Grading of clinical severity developed for use in Kenya and which always be treated as ‘severe’ cases, There is no globally accepted system applies to all ocular allergies. It takes into whatever their presenting clinical signs. consideration the clinical signs present or guidelines for the grading and There are many tools that can be used in during the objective assessment but not management of ocular allergy, although the management of ocular allergy. several authors have proposed such the patient’s symptoms. systems.1-5 Non-pharmacological treatment, All patients with ocular allergy should be Treatment including allergen avoidance and cold graded according to the level of severity.6 The management of ocular allergies in compresses, are important for providing This is because the grade of severity has low- and middle-income countries is short-term relief from symptoms. The patient should also be advised to avoid an impact on clinical decision making and complicated by the high cost of drugs and eye rubbing. helps ascertain the patients’ ocular clinical the limited options available Table 2 details the treatment guidelines status and risk of vision loss. It also helps Topical lubricants, preferably preserv- developed for use in Kenya, based on the to determine the choice of treatment and ative free, are recommended for use in all severity grading. the timing/frequency of follow-up. grades of severity to dilute allergens and Table 1 is based on a simplified clinical Note: Patients diagnosed with vernal reverse tear film instability secondary to grading system which the authors have or atopical keratoconjunctivitis should chronic inflammation.

Table 1. A grading guide based on the Ocular Allergy Clinical Grading Guide developed for use in Kenya. The grading is determined by the most severe sign present in the most severely affected eye

Grade Mild Moderate Severe Papillae Millicent Bore E Lee Stock and David M Meisler Millicent Bore Micro: <0.3mm • Macro: between 0.3 and 0.5 mm • Cobblestone papillae: >0.5 mm • +/– Fibrosis but smaller than 1.0 mm • Giant papillae: >1.0 mm

Conjunctiva Millicent Bore Millicent Bore Millicent Bore Hyperemia • Hyperemia • Hyperemia • Diffuse thin chemosis • Cyst-like chemosis/scar • Conjunctivalisation of the cornea

Limbus (limbal oedema or Horner- Trantas dots) Erhardt Kidson Millicent Bore Millicent Bore No manifestations <½ of limbal circumference ½ or more of limbal affected circumference affected

Cornea Erhardt Kidson Millicent Bore Millicent Bore Clear Superficial punctate keratitis • Shield ulcer/epithelial erosion • Keratoconus +/– central leucoma

Note that patients diagnosed with vernal or atopic keraconjunctivitis should be treated as ‘severe’ cases, whatever their presenting clinical signs.

48 COMMUNITY EYE HEALTH JOURNAL | VOLUME 29 ISSUE 95 | 2016 Table 2. Treatment and follow-up guidelines, based on severity grading (developed for Kenya) Grade Mild Moderate Severe Treatment 1 Topical antihistamine (e.g. 1 Mild topical steroid, e.g. 1 Pulsed topical steroid regimen (start Emedastine) for 1 month fluoromethalone 4 times frequently then taper) +/– topical a day for 1–2 weeks +/– cyclosporine 0.5–2% until good remission, OR steroid ointment at night for then stop. 2–4 weeks 2 Topical antihistamine + mast cell stabiliser/ 2 Multi-action drug, e.g. 2 Mast-cell stabiliser multi-action drug for 1 month then mast cell olopatadine, for 1 month (e.g. cromolyn sodium) stabiliser for maintenance 3 Steroid ointment at night for 2–4 weeks 4 Cobblestone/giant papillae or refractory cases: subtarsal steroid* (e.g. triamcinolone) 5 Shield ulcer: corneal scraping/superficial keratectomy + topical steroid- +/– mydriatic Follow-up 1 As required 1 Review after 4-6 weeks, then 1 Review after 1–2 weeks then monthly while – if stable – as required on steroids 2 Taper steroids (check IOP) 3 Stagger reviews to 3-monthly once patient is stable

*Avoid repeated use or use in children aged less than 10 years due to the risk of elevated IOP

Topical antihistamines and mast cell progression (refractory cases). Their Follow-up stabilisers are considered as first-line use is also recommended in patients Frequency of follow-up is linked to: treatment. Mast cell stabilisers require with severe papillary reaction leading to a loading period of up to two weeks in corneal epithelial erosions/shield ulcers.6 • Clinical severity grading order to achieve maximal efficacy. It • Sight-threatening or non sight- Topical immunomodulators, such as should be combined with an antihis- threatening condition? cyclosporin A, have been shown to be of tamine (short duration of action) or a mild • Clinical response to treatment great benefit as steroid-sparing agents in topical steroid such as fluoromethalone chronic disease7, although they are not A follow-up visit should include recent to provide faster relief. Mast cell therapy readily available. history, measurement of visual acuity, should be continued when the steroids and slit lamp biomicroscopy. If corticos- are stopped. Patient counselling teroids are prescribed, measurement of Dual-action drugs have both antihis- All patients and their carers should be intraocular pressure and pupillary dilation tamine and mast cell stabiliser action. counselled. A well-informed patient should be performed to evaluate for They are effective in treating ocular allergy and parent/guardian will be in a better glaucoma and cataract. and outperform other groups of drugs. position to take part in the management If there is inadequate correction of Another benefit is improved compliance of the condition. Counselling leads to and a history of frequent because of a reduction in the number of improved compliance with changes in spectacle prescriptions, medications to be used. and follow-up visits. It also leads to a suspect keratoconus. Look out for infec- reduction in self-medication, which in turn tions such as viral keratitis and refer all Topical ocular steroids are effective reduces possible misuse of steroids. patients with severe disease (i.e. those (probably the most effective of all It is important to make patients with developing complications) or those not options), but pose the sight-threatening disease responding to treatment. important risk of frequent aware that it can be blinding, side effects (glaucoma, ‘All patients References so that they can understand 1 Takamura E, Uchio E, Ebihara N, Ohno S, Ohashi Y, , corneal ulcers). Okamoto S, et al. Japanese Society of Allergology. the importance of proper Mild topical steroids should and their Japanese guideline for allergic conjunctival diseases. follow-up and keeping their Allergol Int. 2011;60(2): 191-203. be used in acute crises carers should appointments. 2 Bonini S, Sacchetti M, Mantelli F, Lambiase A. Clinical for short periods of time; grading of vernal keratoconjunctivitis. Curr Opin Allergy Counselling can also help preferably less than 2 Clin Immunol. 2007;7(5): 436-41. be counselled.’ patients to avoid the compli- 3 Calonge M, Herreras JM. Clinical grading of atopic weeks. In cases of severe keratoconjunctivitis. Curr Opin Allergy Clin Immunol. cations associated with ocular allergy, a pulsed 2007;7(5): 442-5. chronic eye rubbing (kerato- 4 Sacchetti M, Lambiase A, Mantelli F, Deligianni topical steroid regimen (start frequently, conus) and the overuse or misuse of V, Leonardi A, Bonini S. Tailored approach to the then taper) is advised. The duration of use treatment of vernal keratoconjunctivitis. Ophthalmol. steroids (glaucoma, cataract, etc.). 2010;117(7): 1294-9. is based on the grade of severity. Steroid Talk to patients about what they can 5 Bore M, Ilako DR, Kariuki MM, Nzinga JM. Clinical ointments can be used at night for a short evaluation criteria of ocular allergy by ophthalmologists do to support themselves, e.g. avoiding duration. in Kenya and suggested grading systems. allergens, using cool compresses and JOECSA.2014;18(1): 35-43. 6 Bore M, Ilako DR, Kariuki MM, Nzinga JM. Current The use of supra-tarsal steroids is preservative-free artificial tears, and management of ocular allergy by ophthalmologists in recommended only for severe cases wearing spectacles or sunglasses when Kenya. JOECSA.2014;18(2): 59-67. outside. Basic printed information can be 7 Ozcan AA, Ersoz TR, Dulger E. Management of severe where topical medication does not control allergic conjunctivitis with topical cyclosporin a 0.05% symptoms or when there is disease issued to patients during clinic visits. eyedrops. Cornea. 2007;26(9): 1035-8.

© The author/s and Community Eye Health Journal 2016. This is an Open Access COMMUNITY EYE HEALTH JOURNAL | VOLUME 29 ISSUE 95 | 2016 49 article distributed under the Creative Commons Attribution Non-Commercial License. COMMUNITY EYE HEALTH JOURNAL JOURNAL HEALTH EYE COMMUNITY 50 Common and important ocular surface conditions Condition History and signs Primary level management Infectious conditions Microbial keratitis History: Painful, with reduced vision developing acutely over one or two Hourly antibiotic eye days (bacterial) or sub-acutely over a few days (fungal). drops and refer to a specialist. | Signs: (epithelial defect) with underlying stromal infiltrate. The VOLUME 29 ISSUE 95 95 ISSUE 29 VOLUME conjunctiva will be red. There may be inflammatory cells in the anterior chamber, progressing to a in severe disease. Matthew Burton Viral conjunctivitis History: Red, watering eyes, often bilateral. Normal or reduced vision. Mild pain. Avoid spread to May have associated sore throat and runny nose. others through good hygiene. Self-limiting. | Signs: Watery discharge, conjunctival injection, tarsal conjunctival follicles, 2016 pre-auricular and eyelid oedema. The cornea may be affected with multiple superficial sub-epithelial infiltrates (grey-white spots – see image). Matthew Burton Bacterial History: Red, uncomfortable eyes with purulent discharge. There is usually Avoid spread to redness, grittiness and burning, which may initially have been unilateral but others through good conjunctivitis often becomes bilateral. Lids are often stuck together in the morning with dried hygiene. discharge. Topical for Signs: Conjunctival injection, papillary conjunctivitis, discharge. 5–10 days. P Vijayalakshmi Allergic conjunctivitis Vernal History: Allergic conjunctivitis can present at any age as itching and watering due to Avoid allergens. some known or unknown allergen. A severe form is VKC which presents in childhood Offer antihistamines, keratoconjunctivitis with severe itching, watering, foreign body sensation and thick mucus discharge. mast cell inhibitors, (VKC) Signs: There is conjunctival injection (see image). Papillae are found in the tarsal and/or conjunctiva, which can be large and irregular (cobblestone papillae). Tranta’s spots topical steroids

John Dart are small white dots at the limbus. The limbus can become pigmented. The cornea (short-term). can be affected with plaques and ulceration of the upper cornea. Blepharitis Anterior blepharitis Posterior blepharitis History: Itching, burning, uncomfortable eyes, with or without associated watering Anterior: Lid and dry eye symptoms (see below). There may be an associated history of cleaning to remove recurrent meibomian cysts. crusts. Signs: Hard scales and crusting at the bases of lashes in anterior blepharitis. Look Posterior: Hot for capped or plugged meibomian gland orifices and hyperaemia (redness) of the compresses and lid

John Dart John Dart posterior lid margin in posterior blepharitis. massage. Dry eye Dry eye History: Uncomfortable, gritty eyes with a foreign body sensation. Severe cases Topical artificial tears may be photophobic and painful with reduced vision. (lubricants). Signs: The tear film is abnormal with debris on the surface and a tear break-up time of less than 10 seconds. The tear meniscus may also be thin. Punctate epithelial erosions that stain with fluorescein are the hallmark of dry eye disease. Other inflammatory conditions Peripheral History: Painful, red eye with loss of vision, developing gradually over several Treat as for weeks. May have a history of systemic inflammatory disease. Mooren’s ulcer is an microbial keratitis ulcerative keratitis isolated ocular problem, typically occurring in young males. (see above) and refer (including Mooren’s Signs: Progressive, circumferential stromal thinning and ulceration. The limbus is to a specialist. ulcer) inflamed in the area next to the ulceration. Marginal keratitis History: Moderate pain, mild visual disturbance and redness. Treat initially as for Signs: Blepharitis, subepithelial marginal infiltrates (can be multiple) with an area microbial keratitis. of clear cornea between the infiltrate and the limbus. There may be an epithelial If the diagnosis is defect, which is usually smaller than the infiltrate. confirmed, prescribe a low-dose topical steroid. Other non-inflammatory conditions Neurotrophic History: This should be considered in the context of systemic conditions (e.g. Treat the underlying leprosy) or an ocular cause (e.g. herpetic keratitis or herpes zoster). The patient cause. Protect cornea keratitis presents with a red eye with reduced vision. There may or may not be pain. with lubricants, taping Signs: Interpalpebral punctate epithelial erosions, persistent epithelial defects, the eyelid closed at stromal oedema and infiltration. night, or lid closure.

Ocular surface History: Patients usually present with an awareness of a growing lesion on the Refer for wide ocular surface. This may be uncomfortable or red. There may be pain and reduced surgical excision. squamous vision when large. There may be an association with HIV+ status. neoplasia Examination: Thickened conjunctival epithelium that may extend onto the cornea with prominent ‘feeder’ vessels. There may be surface keratinisation characterised by white patches (leukoplakia), a gelatinous appearance, inflammation or pigmentation. Pterygium History: The patient may complain of a red lump, on one or both sides of the Surgical excision if cornea, which can occasionally become more inflamed and uncomfortable. There vision is threatened. may be blurring of vision, depending on the extent of growth across the cornea, and induced . Examination: There is a fleshy, wing-shaped growth, arising from the conjunctiva, that grows across the cornea.

Hourly antibiotic eye drops and refer to a specialist. Avoid spread to others through good hygiene. Self-limiting. Avoid spread to others through good hygiene. antibiotics for Topical 5–10 days. Avoid allergens. Offer antihistamines, mast cell inhibitors, and/or topical steroids (short-term). Anterior: Lid cleaning to remove crusts. Hot Posterior: compresses and lid massage. as for Treat microbial keratitis (see above) and refer to a specialist. initially as for Treat . microbial keratitis diagnosis is the If confirmed, prescribe a low-dose topical steroid. the underlying Treat cause. Protect cornea with lubricants, taping the eyelid closed at night, or lid closure. Surgical excision if vision is threatened. Primary level management artificial tears Topical (lubricants). Refer for wide surgical excision. The tear film is abnormal with debris on the surface and a break-up time 2016. This is an Open Access article distributed under the Creative Commons Attribution Non-Commercial License. dry eye symptoms (see below). There may be an associated history of Compiled by Jeremy Hoffman, Matthew Burton and Allen Foster of less than 10 seconds. The tear meniscus may also be thin. Punctate epithelial erosions that stain with fluorescein are the hallmark of dry eye disease. Painful, red eye with reduced vision developing acutely over one or two History: Painful, days (bacterial) or sub-acutely over a few (fungal). Signs: Corneal ulcer (epithelial defect) with underlying stromal infiltrate. The conjunctiva will be red. There may inflammatory cells in the anterior chamber, progressing to a hypopyon in severe disease. History: Red, watering eyes, often bilateral. Normal or reduced vision. Mild pain. May have associated sore throat and runny nose. discharge, conjunctival injection, tarsal follicles, Signs: Watery pre-auricular lymphadenopathy and eyelid oedema. The cornea may be affected spots – see image). with multiple superficial sub-epithelial infiltrates (grey-white History: Red, uncomfortable eyes with purulent discharge. There is usually redness, grittiness and burning, which may initially have been unilateral but often becomes bilateral. Lids are stuck together in the morning with dried discharge. Signs: Conjunctival injection, papillary conjunctivitis, discharge. History: Allergic conjunctivitis can present at any age as itching and watering due to which presents in childhood some known or unknown allergen. A severe form is VKC with severe itching, watering, foreign body sensation and thick mucus discharge. are found in the tarsal Signs: There is conjunctival injection (see image). Papillae spots conjunctiva, which can be large and irregular (cobblestone papillae). Tranta’s are small white dots at the limbus. The limbus can become pigmented. cornea can be affected with plaques and ulceration of the upper cornea. History: Itching, burning, uncomfortable eyes, with or without associated watering and recurrent meibomian cysts. Signs: Hard scales and crusting at the bases of lashes in anterior blepharitis. Look for capped or plugged meibomian gland orifices and hyperaemia (redness) of the posterior lid margin in blepharitis. History: Uncomfortable, gritty eyes with a foreign body sensation. Severe cases may be photophobic and painful with reduced vision. Signs: red eye with loss of vision, developing gradually over several History: Painful, weeks. May have a history of systemic inflammatory disease. Mooren’s ulcer is an isolated ocular problem, typically occurring in young males. Signs: Progressive, circumferential stromal thinning and ulceration. The limbus is inflamed in the area next to ulceration. History: Moderate pain, mild visual disturbance and redness. Signs: Blepharitis, subepithelial marginal infiltrates (can be multiple) with an area of clear cornea between the infiltrate and limbus. There may be an epithelial defect, which is usually smaller than the infiltrate. History: This should be considered in the context of systemic conditions (e.g. leprosy) or an ocular cause (e.g. herpetic keratitis herpes zoster). The patient presents with a red eye reduced vision. There may or not be pain. Signs: Interpalpebral punctate epithelial erosions, persistent defects, stromal oedema and infiltration. usually present with an awareness of a growing lesion on the History: Patients ocular surface. This may be uncomfortable or red. There pain and reduced vision when large. There may be an association with HIV+ status. Examination: Thickened conjunctival epithelium that may extend onto the cornea with prominent ‘feeder’ vessels. There may be surface keratinisation characterised by white patches (leukoplakia), a gelatinous appearance, inflammation or pigmentation. History: The patient may complain of a red lump, on one or both sides the cornea, which can occasionally become more inflamed and uncomfortable. There may be blurring of vision, depending on the extent growth across cornea, and induced astigmatism. wing-shaped growth, arising from the conjunctiva, Examination: There is a fleshy, that grows across the cornea. History and signs © The author/s and Community Eye Health Journal Vernal Vernal keratoconjunctivitis (VKC) Viral conjunctivitis Bacterial conjunctivitis Dry eye Peripheral ulcerative keratitis (including Mooren’s ulcer) Marginal keratitis Neurotrophic keratitis Ocular surface squamous neoplasia Pterygium Microbial keratitis

Condition Matthew Burton Matthew Burton Matthew Burton Matthew Burton Matthew Dart John Allergic conjunctivitis Blepharitis Dry eye Dart John Other inflammatory conditions Other non-inflammatory conditions Infectious conditions

COMMUNITY EYE HEALTH JOURNAL | VOLUME 29 ISSUE 95 | 2016 51 CANCER OF THE CONJUNCTIVA Squamous cell carcinoma of the conjunctiva

Stephen Gichuhi often normal in the early stages. It usually abrupt transition between the normal Consultant Ophthalmologist and Senior only involves one eye. The surface may and abnormal tissues. However, histo- Lecturer: Department of Ophthalmology, be gelatinous, papillomatous or fibro- pathology is not without challenges. It University of Nairobi, Kenya. vascular. There is usually inflammation, requires surgical intervention for excision Mandeep S Sagoo leukoplakia and markedly dilated blood and the interpretation is subjective, Consultant Ophthalmic Surgeon: vessels, referred to as feeder vessels. varying between pathologists. It is particu- Ocular Oncology Service, Moorfields Some brown to black pigmentation of the larly challenging in the earlier stages of Eye Hospital and Senior Lecturer: UCL lesion is common in African population OSSN, when it is pre-cancerous. After Institute of Ophthalmology, London, UK. groups. Most lesions are about 7 mm excision, the specimen often rolls up wide at presentation but late presen- if immediately put in formalin, making Introduction tation with large orbital tumours are not orientation difficult. This can be counter- and epidemiology uncommon. acted by first placing the specimen on Squamous cell carcinoma of the sterile suture packing foam for a few conjunctiva is the end-stage of a Diagnosis minutes to stiffen before putting it in spectrum of disease referred to as ocular Most cases are diagnosed from the formalin. Fragmentation of small tumour surface squamous neoplasia (OSSN). clinical impression. There is a shortage specimens and shearing of the surface OSSN is a malignant disease of the eyes of histopathology services in most layers may occur during processing, that can lead to loss of vision and, in equatorial countries; however, even in making the judgement of depth of severe cases, death. The main risk factors countries without this limitation, about involvement difficult. for both are exposure to solar ultraviolet half of the lesions are not excised for Although vital staining with topical radiation outdoors, HIV/AIDS, human histopathology. This may be related toluidine blue 0.05% stains most lesions papilloma virus and allergic conjunctivitis. to the increasing trend to treat these dark royal blue with a high sensitivity, the The limbal epithelial cells appear to be the lesions with primary topical medication. specificity is low due to false positives in progenitorsof this disease. However, the clinical impression is benign lesions (Figure 2).4 OSSN is an important ophthalmic unreliable, especially in equatorial , problem in equatorial as both benign and malignant lesions Treatment Africa, where there are both high levels have overlapping features. There is also Surgical excision under the microscope of UV radiation and a high incidence of the ethical consideration of using poten- is the most commonly used technique. HIV/AIDS. Africa has the highest incidence tially dangerous topical medications, Small lesions are simply excised in total of OSSN in the world, affecting about such as cytotoxic drugs, without a tissue while larger ones involving the orbit may 1.3 people per 100,000 population per diagnosis. need exenteration, a radical technique year; so, if you work in an eye clinic Histopathology is the gold standard that involves removing all the orbital serving a population of 1 million people, for diagnosis: the pathologist will see an contents including the periosteum. you could expect to see one case each Figure 1. A range of OSSN presentations seen in East Africa.1 month if they all came to the clinic.1 By contrast, the incidence in other regions is about 0.1 people per 100,000 population per year, over 10 times lower. Two disease patterns occur. In equatorial Africa, OSSN affects younger adults and proportionally more women than in other parts of the world. Recent studies in Kenya, for example, found that the mean age of OSSN patients is around 40 years, two-thirds are women and

about three-quarters are living with HIV. Stephen Gichuhi Stephen Gichuhi Elsewhere, OSSN affects older adults (the Small lesion with leukoplakia Medium-sized lesion with pigmentation mean age is about 60 years) and 70% are male. Clinical presentation This disease has a variable appearance (Figure 1). Red eye, photophobia, irritation, foreign body sensation and a white, painless, progressive growth on the surface of the eye are common presenting symptoms.2 Most lesions occur in the interpalpebral fissure, 3

especially on the nasal side. They involve Stephen Gichuhi Stephen Gichuhi the conjunctiva and may extend onto Large lesion with corneal extension but Very large lesion extending into the the peripheral cornea, so visual acuity is not involving the fornices orbit

52 COMMUNITY EYE HEALTH JOURNAL | VOLUME 29 ISSUE 95 | 2016 Figure 2. Conjunctival lesions before and after staining with 0.05% toluidine blue. drops applied 4 times daily after the The pictures in the left column are before staining and those on the right after excision site healed (usually 2–3 weeks staining. Images A and B show moderately differentiated squamous cell carcinoma, after excision) for OSSN lesions <2 with deep royal blue staining. C and D show , with mixed staining quadrants in diameter.5 It decreased the (margin and parts of the lesion). risk of recurrence one year after excision from 36% to 11%.There were transient adverse effects such as a watery eye, discomfort when applying the drops and eyelid inflammation, which settled within 2–3 weeks after completion of treatment. In Kenya the estimated cost of a 4-week treatment course of 5FU eyedrops is 320 Kenyan shillings (US $3.20). Follow-up Stephen Gichuhi Stephen Gichuhi Follow-up is important to monitor for recurrence, including everting the upper eyelid in case of recurrent tumour on the tarsal conjunctiva. Most recurrences in sub-Saharan Africa present early (3 and 6 months later). Reviews in this region should ideally be done 1, 3 and 6 months after surgery. After one year, reviews may be conducted at month 18, 24 and 36 after surgery. For large lesions

Stephen Gichuhi Stephen Gichuhi that need more radical surgery, the follow-up regimes vary. Some surgeons Lesions are excised with a 4 mm margin, 5-fluorouracil (5FU) and mitomycin C, use radiotherapy after surgery. dissecting down to the sclera without may be applied to the bed for about touching the tumour. Some surgeons 2.5 minutes then washed off. Other Patient counselling use the bare sclera technique which agents include interferon alpha 2b There is no word for OSSN in most local allows the conjunctiva to re-epithelialise, drops, cyclosporin A, all-trans retinoic languages. Calm reassurance is needed, whereas others mobilise the surrounding acid, anti-VEGF agents and radiotherapy. especially as this cancer tends not to conjunctiva for primary closure of Many centres in Africa do not have metastasise and in the majority of cases the defect and earlier post-operative cryotherapy or other adjuvants, except is not life threatening. Most patients adjuvant chemotherapy. Other ways of for 5FU, which is frequently available. will be anxious when told that they have closing the defect are by autologous Topical antibiotic-steroid combination cancer in their eye. In those living with conjunctival graft from the other eye or eyedrops are applied 4 times daily for HIV, this may be compounded by other by using commercially available amniotic about 3–4 weeks after the primary concerns related to the complications of membrane. Absolute alcohol is applied excision, until the site heals. HIV. For people with large orbital tumours to the corneal extension of the lesion to Recurrence after the primary excision there may be fear of general anaesthesia. loosen the tissue from the cornea, so can be frequent. Surgical excision The possibility of recurrence and the need that it can be dissected microsurgically alone is associated with recurrences to follow up in the clinic is essential. with a blade. of 3.2% to 67% at an average of 32 It is helpful to give patients evidence Adjuvant therapies to augment months. HIV testing and treatment of the success of surgical excision with surgery include cryotherapy, where should be considered standard practice adjuvant therapy (for smaller lesions). 2–4 freeze-thaw cycles are used to oblit- for all patients presenting with OSSN. For example, former patients who are erate residual tumour at the bed and We recently conducted a randomised willing to share their experiences with margins. Topical cytotoxic drugs, such as controlled trial of topical 5FU 1% eye other patients can be very helpful ‘change agents,’ and can reassure and encourage Figure 3. Picture A shows the pre-operative appearance of a lesion in a 32-year-old others to come for treatment. woman. She was HIV infected with a CD4 count of 69 cells/µL. The lesion was excised with a 4 mm margin. She was given topical Gentamycin and Prednisolone drops 4 times References 1 Gichuhi S, Sagoo MS, Weiss HA, Burton MJ. daily for 3 weeks. Histopathology showed moderately differentiated squamous cell Epidemiology of ocular surface squamous neoplasia in carcinoma. She was given 1% 5FU drops to apply 4 times daily for 4 weeks. Africa. Trop Med Int Health 2013; 18(12): 1424-43. (B) shows the eye about a year later; the lesion had not recurred. 2 Tunc M, Char DH, Crawford B, Miller T. Intraepithelial and invasive squamous cell carcinoma of the conjunctiva: analysis of 60 cases. Br J Ophthalmol A B 1999; 83(1): 98-103. 3 Waddell KM, Downing RG, Lucas SB, Newton R. Corneo-conjunctival carcinoma in . Eye (Lond) 2006; 20(8): 893-9. 4 Gichuhi S, Macharia E, Kabiru J, et al. Toluidine Blue 0.05% Vital Staining for the Diagnosis of Ocular Surface Squamous Neoplasia in Kenya. JAMA Ophthalmol 2015; 133(11): 1314-21. 5 Gichuhi S, Macharia E, Kabiru J, et al. Topical fluorouracil after surgery for ocular surface squamous neoplasia in Kenya: a randomised, double-blind, placebo-controlled trial. Lancet Glob Health 2016;

Stephen Gichuhi Stephen Gichuhi 4(6): e378-e85.

© The author/s and Community Eye Health Journal 2016. This is an Open Access COMMUNITY EYE HEALTH JOURNAL | VOLUME 29 ISSUE 95 | 2016 53 article distributed under the Creative Commons Attribution Non-Commercial License. PTERYGIUM Understanding and managing pterygium

Anthony Bennett Hall to see if the symptoms have improved Consultant Ophthalmologist: Hunter with conservative treatment and to check Eye Surgeons, Newcastle Eye Hospital, if the pterygium has grown. Newcastle, Australia. Use an information leaflet to help you A pterygium is a wing-shaped fibrovas- to counsel patients. We use a leaflet cular proliferation of the conjunctiva that which has a picture of a pterygium, a grows across the cornea.1 Pterygium list of indications, a description of the occurs more frequently in people who live procedure, what to expect in the post- in areas with high ultraviolet radiation. operative period, possible complications, Dusty, hot, dry, windy, and smoky and the likelihood of recurrence. The 2 environments also play a part. Most Anthony Bennett Hall picture is useful in helping you to explain occur on the nasal side. Pterygium examined using a slit lamp the diagnosis, the indications for surgery and the pterygium operation. Warn be valuable in detecting irregular astig- Diagnosis patients that the eye may be quite painful matism and distortion caused or induced for a day or two. Step 1. Taking a detailed history by pterygium. How long has the growth been present? Typically, this would be for many months Complications When to treat Patients need to be fully informed or years. This helps to differentiate it The most important indications for about possible complications before from ocular surface squamous neoplasia treatment are: (OSSN), which tends to have a shorter you start. history (see pages 52–53). • Involvement of, or threat to, the visual Complications can occur during the Ask the patient if it has been getting axis operation or may present later. bigger. Some pterygia are inactive and • Loss of vision from astigmatism Intraoperative complications include: have not grown for decades. • Restriction of eye movement • Perforation of the globe What symptoms is the patient • Atypical appearance suggesting • Thinning of sclera or cornea from complaining of? There may be redness, dysplasia dissection irritation, blurring of vision, double • Increasing size (documented by an • Intraoperative bleeding vision, itching, and a concern about the ophthalmologist) • Excessive cautery cosmetic appearance.3 Less important indications are: • Muscle damage • Reversing the conjunctival autograft Step 2: Examination • Increasing size (reported by the patient) (placing it epithelial surface down) Check the visual acuity. You should • Symptoms of irritation and complaints always do a complete eye examination of redness, etc. Early postoperative complications and look for other causes of discomfort or • Cosmetic issues include: vision loss. • Persistent epithelial defects Measure the size of the pterygium from Counselling patients • Dellen formation (an area of corneal the limbus to the apex of the pterygium Patients benefit from counselling before thinning adjacent to limbal swelling on the cornea. Record this on a diagram and after the operation. that prevents normal wetting of the in the clinical record so that, the next time Not every pterygium needs to be corneal surface) you see the patient, you can tell if the operated on. Some patients may expect • Haematoma beneath the graft pterygium has grown. to have their pterygium removed when • Loss of the graft Look for any atypical simple conservative • features that might ‘You should always treatments such as make you worry about lubricating drops or Late complications include: dysplasia (early-stage do a complete eye steroids may be all • Recurrence cancer), such as leuco- that is needed. It is • Corneo-scleral necrosis plakia (an elevated, examination and important to explain • white, dry-looking patch), to patients that there look for other • a raised gelatinous mass, is a chance of recur- or a large, prominent causes of rence, so the pterygium Recurrence is a major late complication. feeder blood vessel. Be may come back even The highest rate of recurrence occurs in especially alert if you discomfort or if it has been surgi- the bare sclera technique.1,5 The section live in Africa where there vision loss.’ cally removed. However, opposite describes a technique of is a high prevalence of surgery with a conjunc- excision with conjunctival autografting, OSSN.4 tival graft (as described which reduces the recurrence rate.1 You Examine the eye movements to look opposite) substantially reduces the risk may wish to consider using adjuvants for any evidence of restricted movement of recurrence. such as 5-fluorouracil or mitomycin C, caused by the pterygium. Compile a list of indications to suit but be aware that mitomycin C is Retinoscopy will reveal any with-the- your setting. Use the list to counsel associated with a higher rate of visually rule astigmatism that may be caused by patients about their suitability for an threatening complications. Adjuvants can the pterygium. Corneal topography can operation. Review them in a few months be reserved for recurrent cases.1

54 COMMUNITY EYE HEALTH JOURNAL | VOLUME 29 ISSUE 95 | 2016 Pterygium surgery: the conjunctival autografting technique

Before the operation conjunctival sac with 5% (aqueous) elevate the pterygium off the sclera and Consider using steroids for a few days povidone iodine solution, and drape separate the conjunctival epithelium preoperatively to reduce inflammation. the patient. A scrub nurse should assist from the underlying Tenon’s capsule. Before you begin giving the anaes- you. A surgical pack containing an eyelid The vasoconstrictive effect will also thetic, check the notes to make sure speculum, two pairs of Moorfield’s limit bleeding. A traction suture may be you are proceeding on the correct eye. forceps, fine-toothed forceps, Wescott needed to move the eye if the patient has Mark the eye, as you would for any eye scissors, needle holder, crescent blade or had a block. This may be inserted through procedure, to avoid possible confusion. No. 15 blade, bipolar or ball cautery, fine the superior peri-limbal conjunctival Give the patient topical anaesthetic absorbable suture (7-0 or 9-0) or 10-0 tissues or be a corneal traction suture. nylon and swabs. drops before they come into the theatre. Excising the pterygium Dilating drops will help reduce the pain Even if you have given a sub-Tenon’s To get a good view, ask the patient to look from postoperative ciliary spasm.5 block, injecting anaesthetic with adren- aline under the conjunctiva will help to in the direction away from the pterygium. Anaesthesia Start the excision of the Figure 1. Dissecting pterygium off the limbus pterygium by grasping it with If you have a cooperative Moorfields forceps and making patient, you can infiltrate radial incisions with Wescott local anaesthetic under the scissors along the edges. Find conjunctiva using a fine-gauge the plane under the pterygium needle. Use a long-acting and Tenon’s capsule anterior anaesthetic such as bupiv- to the medial rectus muscle. acaine as this can give some Take care to stay away from hours of pain relief after the the medial rectus muscle so operation. Adrenaline will aid that it is not cut or damaged haemostasis. inadvertently. Cut along the Infiltrate the anaesthetic base of the pterygium (parallel under the pterygium and under to the limbus). Make sure you the conjunctival epithelium stay anterior to the plica. The supero-temporally. The Anthony Bennett Hall pterygium should lift easily advantage of local infiltration off the sclera. It becomes is that the patient retains the Figure 2. Dissecting thin graft off Tenon’s capsule adherent at the limbus and ability to move the eye and can you will need to use a crescent be asked to look left, right or blade or No. 15 blade to down to expose the part of the carefully dissect it off the eye that is being operated on. cornea (Figure 1). The sclera Give a sub-Tenon’s anaes- must be clean of any Tenon’s thetic if the patient is likely capsule. to be uncooperative or if you Ask your assistant to keep anticipate a lengthy procedure. the field free of blood so that You will need to reassure the you have a clear view of the patient and explain each step depth of your dissection. as you proceed with the anaes- Most bleeding will stop of thesia and the excision. its own accord. Only use cautery if the bleeding is so

Pterygium Anthony Bennett Hall profuse that it is likely to form excision and a large haematoma and lift Figure 3. Suturing limbal corner of graft to sclera the conjunctival graft off the autoconjunctival sclera. A little blood will act as graft autologous fibrin glue. Pterygium surgery should not be delegated to the most junior Taking the trainee surgeon. Supervision of trainees should be continued conjunctival until they are competent at all autograft the steps required. This will Ask the patient to look down. reduce recurrence rates.3 Marking the epithelium with Prepare the patient as a sterile skin marker will help you would for intraocular you to identify the surface surgery. Wear a sterile gown of the graft. Make two radial and gloves, disinfect the incisions in the superior

skin around the eye and the Anthony Bennett Hall Continues overleaf ➤

COMMUNITY EYE HEALTH JOURNAL | VOLUME 29 ISSUE 95 | 2016 55 PTERYGIUM Continued bulbar conjunctiva. The incisions should Figure 4. Graft one week after surgery antibiotic drops 4 times a day for a week. outline an area that is about the same The topical steroid should continue for at in size as the nasal conjunctival defect. least a month. Carefully dissect the conjunctiva off the Examine the patient the next day to underlying Tenon’s capsule (Figure 2). make sure that the graft is in place. Once you are in the correct plane you The next visit is at 1 week (Figure 4). should incise the conjunctival graft along Review the patient at 1 month and its posterior edge. Lift the posterior edge 3 months to make sure there are no and carefully dissect off any adherent complications. of Tenon’s capsule. Your assistant may recurrence usually occur 4–6 weeks after hold one corner of the graft for you. The surgery.5 graft may be placed epithelium up on a Encourage the patient to return in a paper template (suture cover) before it Anthony Bennett Hall year so that you can check for any recur- is cut off from the limbus. This improves sclera to avoid posterior migration of the rence of the pterygium. the handling and orientation of the thin graft (Figure 3). Suture the remaining conjunctival tissue.2 References corners of the graft to the nasal 1 Kaufman SC, Jacobs DS, Lee WB, Deng SX, Rosenblatt conjunctiva. If you are using nylon, use a MI, Shtein RM. Options and adjuvants in surgery Placing and suturing the mattress suture to bury the knots. Place for pterygium: a report by the American Academy of Ophthalmology. Ophthalmol 2013;120(1):201-8. graft additional sutures as required to close Epub 2012/10/16. Orientate the graft with the limbal donor any gaps between the graft and the 2 Koranyi G, Seregard S, Kopp ED. Cut and paste: a no suture, small incision approach to pterygium surgery. Br edge closest to the nasal limbus. nasal conjunctiva. J Ophthalmol. 2004;88(7):911-4. Epub 2004/06/19. Fibrin glue can speed up pterygium Apply chloramphenicol ointment to the 3 Hirst LW. The treatment of pterygium. Surv Ophthalmol. conjunctiva and firmly pad the eye. 2003;48(2):145-80. Epub 2003/04/11. surgery and may reduce postoperative 4 Gichuhi S, Sagoo MS, Weiss HA, Burton MJ. pain.2 However, the cost of fibrin glue is Epidemiology of ocular surface squamous neoplasia in prohibitive, even in some high-resource Postoperative care Africa. Trop Med Int Health. 2013;18(12):1424-43. Epub 2013/11/19. settings. A good alternative is 9-0 or 10-0 The patient will need good pain relief after 5 Sheppard JD, Mansur A, Comstock TL, Hovanesian nylon: it is widely available, cheap, and surgery. We prescribe a combination of JA. An update on the surgical management of 5 pterygium and the role of loteprednol etabonate causes no tissue reaction. paracetamol and codeine for a day or two. ointment. Clin Ophthalmol. 2014;8:1105-18. Epub Anchor the two limbal corners to the Ask the patient to instil steroid and 2014/06/27.

© The author/s and Community Eye Health Journal 2016. This is an Open Access article distributed under the Creative Commons Attribution Non-Commercial License.

CLINICAL SKILLS FOR OPHTHALMOLOGY

How to irrigate the eye Heiko Philippin

Sue Stevens • For severe acid or alkali burns, Former Nurse Advisor, Community Eye emergency irrigation should continue Health Journal, International Centre for for at least 15 minutes; 30 minutes Eye Health, London School of Hygiene and Tropical Medicine, London, UK. is better. It is advisable to continue to irrigate acid/alkali burn injuries for a Remember to your hands before further 12–24 hours by setting up a and after performing all procedures. saline drip to continue to gently irrigate Indications the eye. • To remove single or multiple foreign You will need: bodies from the eye • A large syringe or a small receptacle Irrigating • To wash the eye thoroughly following with a pouring spout, such as a feeding the eye any chemical injury to the eye cup • Irrigating fluid (normal saline or clean Note: Irrigation of the conjunctival sac • Ask the patient to fix his/her gaze ahead. water at room temperature) is an emergency treatment if there has • Open the eyelids. If necessary, gently • Local anaesthetic eye drops been chemical injury to the eye. use eyelid retractors. • Towel or gauze swabs • Pour or syringe the fluid slowly and steadily, Alkali (e.g. lime) and acid (e.g. car battery) • Lid retractors if available from no more than 5 centimetres away, solutions in the eye may cause serious • A bowl or kidney dish damage to the cornea and conjunctiva, onto the front surface of the eye, inside resulting in long-term loss of vision. Method the lower eyelid and under the upper The sooner the chemical can be • Instil local anaesthetic eye drops. eyelid. diluted and removed, the less likely there • With the patient lying down, protect the • If possible, evert the upper eyelid to is to be damage to the ocular surface. neck and shoulders with a towel or sheet. access all of the upper conjunctival fornix. Immediate, copious irrigation may • Place the bowl or kidney dish against • Ask the patient to move the eye in all save the eye after chemical injury. the cheek, on the affected side, with the directions while the irrigation is maintained. head tilted sideways towards it. • Check and record the visual acuity when • For foreign body removal, a minute or • Fill the feeding cup or syringe with the the procedure is finished. so of irrigation should be sufficient to irrigating fluid and test the temperature • In alkali and acid burns, refer the patient remove any foreign bodies. on your hand. to an ophthalmologist for assessment.

56 COMMUNITY EYE HEALTH JOURNAL | VOLUME 29 ISSUE 95 | 2016 © The author/s and Community Eye Health Journal 2016. This is an Open Access article distributed under the Creative Commons Attribution Non-Commercial License. EQUIPMENT CARE AND MAINTENANCE Sponsored by the IAPB Standard List: a great platform to source and compare eye health products www.iapb.standardlist.org Understanding and caring for an indirect ophthalmoscope

Ismael Cordero Figure 1. How an indirect ophthalmoscope works Clinical Engineer, Philadelphia, USA. [email protected] Examiner

The binocular indirect ophthalmoscope, or indirect ophthalmoscope, is an optical instrument worn on the examiner’s head, Aerial image and sometimes attached to spectacles, of retina Patient that is used to inspect the fundus or back of the eye. It produces an stereo- scopic image with between 2x and 5x Bulb magnification. It is valuable for diagnosis and treatment of retinal tears, holes, and Mirrors Hand-held detachments. The must be fully condenser lens dilated for it to work well. In a dark room, the examiner orien- tates his/her head so that light from the internal light source is directed into Ismael Cordero the patient’s eye. A positive-powered offering 3x magnification and a field of These make it possible to use the indirect condensing lens is held by the examiner view of approximately 45°. A +30D lens ophthalmoscope without the movement at its focal length from the patient’s eye, will offer 2x magnification along with a restrictions caused by power cables. serving two purposes (Figure 1): field of approximately 65°. These higher The indirect ophthalmoscope offers powered lenses are commonly used to some advantages over the direct ophthal- 1 The lens ‘condenses’ light from the examine small children and those with moscope: illumination system towards the small pupils. They can be thought of as patient’s . • It permits with depth more forgiving than the lower-powered 2 Light reflected from the retina passes perception (stereoscopic vision). lenses, and as such are often advocated back through the lens creating a real, • It has a wider field of view. as a good choice of lens for those new to horizontally and laterally inverted image • It can be combined with scleral the indirect ophthalmoscope. of the fundus situated between the indentation to examine the anterior Indirect ophthalmoscopes use halogen lens and the examiner. retina. bulbs as the light source although many • It is not affected by the refractive state The viewing system of the instrument newer models use LED light sources of the patient’ eye. (Figure 2) consists of a pair of low- which operate much cooler and last much • It may be used in the operating room powered convex lenses. This design longer. The newer models may incor- without contamination. affords the examiner a stereoscopic view porate battery packs that can be worn • It accommodates a larger and of the virtual image. The +20D lens is on the examiner’s belt or can even be brighter light source, which permits the standard lens for general examination incorporated into the headband itself. the examiner to penetrate moderate cataracts and to see more retinal detail. Figure 2. Indirect ophthalmoscope viewing system Care Headband size • Keep the instrument in its case when adjustment Headband height not in use. knob adjustment knob Band tension • Make sure the on-off switch is fully knob turned off (a click sound will be heard) before placing the instrument in its case. • Recharge the batteries at the end of Bulb (inside) each work day. Battery • Wipe the headband and the instrument Angle knob surfaces with a cloth dampened in mild Filter lever disinfectant every day. Band tension • Clean the lens by using hard contact Mirror angle knob lens cleaner and warm water and then control drying it with a soft, lint-free cloth. Aperture Brightness selection lever • If needed, sterilise the condensing lens control knob by placing the lens in a cidex solution Eyepiece for 5–10 minutes, by ethylene oxide sterilisation, or by placing it in a formalin chamber. You can also autoclave the Front window lens in a steel chamber with perforation

Ismael Cordero for steam.

© The author/s and Community Eye Health Journal 2016. This is an Open Access COMMUNITY EYE HEALTH JOURNAL | VOLUME 29 ISSUE 95 | 2016 57 article distributed under the Creative Commons Attribution Non-Commercial License. TRACHOMA UPDATE SERIES The Trachoma Update series is kindly sponsored by the International Coalition for Trachoma Control, www.trachomacoalition.org A case for South-South collaboration for trachoma elimination Mwele Malecela, Upendo Mwingira, Sultani tives of the programme, which Matendechero, Michael Gichangi, Rebecca was struggling to gain acceptance and Oenga, Paul Emerson, Teshome Gebre and traction in the Maasai communities, was Girija Sankar. inspired by the experience of the Kenyans, The East Africa NTD/Trachoma Cross-Border Birgit Bolton for ITI who had spent more time gaining Partnership brings together represent- the trust of the Masaai communities, atives from the same ‘neighbourhood’ resulting in them becoming partners in – Eritrea, Ethiopia, Kenya, , the programme and actively seeking out Sudan, Tanzania and Uganda – to share trachoma treatment and surgical services. experiences of common interest in the Similar meetings are planned for the delivery of trachoma and other neglected countries along the Ateker corridor. (NTD) programmes. These countries understand that they will A case for regional networks never reach their individual elimination The East Africa partnership is proving to be targets without working together: they an essential framework for supporting this are all home to nomadic populations of group of national programmes, and is a pastoralists who live on both sides of an model that should be replicated wherever international border and are bound more there are similar groupings of countries closely by relations, socio-cultural activ- Mass drug administration (MDA) amongst that share common issues. For example, ities and trade than by borders.There are Maasai communities in Monduli district. countries in Southern Africa, comprising also common programmatic challenges TANZANIA Malawi, Mozambique, Zambia, and because of shared histories, ethnic- Zimbabwe, will benefit from emulating ities, and languages, an understanding Countries also planned ways to this model because they share some and appreciation of which are critical to synchronise mass drug administration common ethnicities and languages. provide effective public health services. activities, share health education materials, The islands of the South Pacific – Fiji, The Ministry of Health, Community assist in human resource development Kiribati, Papua New Guinea, Solomon Development, Gender, Elderly and (where gaps were identified), enhance Islands, and Vanuatu – share common Children in Tanzania hosted the second efforts on facial and environmental operational issues and can benefit from a annual meeting of this partnership in hygiene in villages and schools along the regional knowledge-sharing network. The August 2016. The discussion fostered by border, and collaborate on surveys. partnerships can go far beyond knowledge the three days of meetings were inspira- Global alliances of NGOs and donors sharing and include practical solutions tional, educational and led to concrete can offer technical and financial resources such as the sharing of surgeons that actions that will accelerate progress but it is the country programmes that speak the same language. They can also towards the elimination of blinding are the engines of disease elimination. enhance efficiency by minimising repli- trachoma and other NTDs. The programme staff best able to under- cation and providing a platform for district stand the problems and identify solutions teams to learn and benefit from each Finding ways forward for their local contexts are those who other’s strengths to improve programmes. One of the highlights was the first meeting work in close proximity National NTD programmes of the district officials with responsi- with the communities “The East Africa have to be able to see what is bility for implementing the programmes they serve on a day-to-day possible and learn from their for Maasai communities in Kenya and basis. However, when the partnership is successes and failures, as Tanzania. They were able to share their policies they are imple- well as those of their neigh- successes and challenges in working with menting are not working, proving to be bours, to plan and deliver the Maasai, leading to several ‘lightbulb’ the next best place to look an essential effective services. Similar moments of greater understanding. for solutions is an adjacent cross-border collaborations Likewise, representatives from Ethiopia, district where different framework” have recently been reported Kenya, South Sudan and Uganda (home solutions may have been in the control to the Ateker people, comprising the Jie, developed for a similar programmes in the Mano Karamajong, Nyangatom, Turkana, and set of problems. Global alliances can River Union (West Africa) with very similar Toposa tribal groups) identified areas for provide the framework for such knowledge findings and recommendations. collaborative engagements in NTD and sharing, but it is when district officials With unprecedented resource mobili- trachoma service provision along the adapt (and extend) these frameworks that sation for NTDs, it is now hard to describe Ateker corridor, including coordinating the success of service delivery is evident. these diseases of neglected people as surgical services and sharing Ateker- For example, a few weeks after the Arusha themselves neglected. For the resources speaking surgeons. The Galabat East meeting, district health officials from to be best utilised, however, delivery district in Sudan and the Metema district Longido, Tanzania and Kajiado, Kenya programmes must be efficient and in Ethiopia have reached their trachoma met in a border town to finalise a coordi- effective. Sharing experiences can save elimination targets and plans are now in nated work plan to provide services for the country programmes years of trial and place for joint surveillance activities on Maasai population on both sides of the error and improve access to freedom from either side of the border. border. During the meeting, representa- disease for all.

58 COMMUNITY EYE HEALTH JOURNAL | VOLUME 29 ISSUE 95 | 2016 © The author/s and Community Eye Health Journal 2016. This is an Open Access article distributed under the Creative Commons Attribution Non-Commercial License.

, CONTINUING PROFESSIONAL DEVELOPMENT (CPD) Test your knowledge and understanding This page is designed to help you to test your own understanding of the concepts covered in this issue, and to reflect on what you have learnt. We hope that you will also discuss the questions with your colleagues and other members of the eye care team, perhaps in a journal club. To complete the activities online – and get instant feedback – please visit www.cehjournal.org 1. Ocular surface disease may affect the following: Tick all that apply Picture quiz a Conjunctiva ICEH b Tear film

c

d Cornea

e Eyelid margins 2. What is important in the treatment of blepharoconjunctivitis? Tick all that apply a Systemic prednisolone

b Tarsorrhaphy This ten-year-old boy presents with itchy, c Warm compresses to the eyelids watering eyes with a thick mucous discharge d Topical atropine of several months’ duration. His visual acuity is 6/9 and 6/12. e Mechanical debridement of crusts 3. : Tick all that apply Q1. Which of the following signs are visible? (tick all that apply) a Is more common with increasing age a. Follicles b Is improved by a hot, dry atmosphere b. Horner-Trantas dots c Can cause punctate epithelial erosions c. Giant papillae d Can be treated with artificial tears d. Pannus

e May result in Mooren’s ulcer e. Trachomatous inflammation 4. Which of these statements are true? Tick all that apply Q2. Which of the following is the most likely Stevens Johnson Syndrome may be associated with HIV diagnosis? (tick one) a positive status a. Bacterial conjunctivitis b Epiphora means a dry eye b. Trachoma c Vernal keratoconjunctivitis is associated with keratoconus c. Kaposi’s sarcoma

d Herpes zoster ophthalmicus may cause corneal anaesthesia d. Vernal conjunctivitis e. Adenoviral conjunctivitis e Alkali burns to the eye are usually more serious than acid burns

5. The following are useful diagnostic tests in ocular surface disease: Tick all that apply Q3. Which of the following may be used in treatment? (tick all that apply) a Direct ophthalmoscopy a. Topical prednisolone b Slit lamp examination of the tear film b. Topical antihistamines c Fluorescein staining of the cornea c. Topical mast cell inhibitors

d Testing for corneal sensation d. Topical acyclovir e. Topical neomycin

e Schirmer’s test

have a role. a have

5. All are true except a. except true are All 5. ANSWERS

ANSWERS all may prednisolone and antihistamines inhibitors, cell

syndrome may be due to an adverse reaction to some medications. some to reaction adverse an to due be may syndrome

inflammation from mast cell degranulation, so mast mast so degranulation, cell mast from inflammation

. Epiphora means a watering eye. Note: Stevens-Johnson Stevens-Johnson Note: eye. watering a means Epiphora . b except true are answers the All 4.

Treatment is to reduce reduce to is Treatment c. and b a, Answer 3.

syndrome does not cause Mooren’s ulcer. Mooren’s cause not does syndrome

adenovirus is self-limiting and does not have giant papillae. giant have not does and self-limiting is adenovirus are correct. Hot dry atmospheres make dry eye symptoms worse. Dry eye eye Dry worse. symptoms eye dry make atmospheres dry Hot correct. are d and c a, Answers 3.

purulent discharge, trachoma often shows follicles, and and follicles, shows often trachoma discharge, purulent important, together with eyelid massage. eyelid with together important,

conjunctivitis. Bacterial conjunctivitis is associated with a a with associated is conjunctivitis Bacterial conjunctivitis. Hot bathing and removal of any debris at the base of the eyelashes are are eyelashes the of base the at debris any of removal and bathing Hot e. and c Answers 2.

The most likely diagnosis is vernal vernal is diagnosis likely most The d. Answer 2. the deep tissues such as (iris) and retina. and (iris) uvea as such tissues deep the

As the name indicates, the surface of the eye can be affected, but not not but affected, be can eye the of surface the indicates, name the As e. and d b, a, Answers 1.

is no evidence of follicles or trachoma. or follicles of evidence no is

on the limbus, which is not visible in this picture. There There picture. this in visible not is which limbus, the on

REFLECTIVE LEARNING seen be may dots Horner-Trantas eyelid. upper the on

mm) mm) (>1.0 papillae giant shows slide The c. Answer

Visit www.cehjournal.org to complete the online ‘Time to reflect’ section. 1.

© The author/s and Community Eye Health Journal 2016. This is an Open Access COMMUNITYCOMMUNITY EYEEYE HEALTHHEALTH JOURNALJOURNAL || VOLUMEVOLUME 2929 ISSUEISSUE 9593 | | 2016 2016 59 article distributed under the Creative Commons Attribution Non-Commercial License. NEWS AND NOTICES

Next issue: online only 1,150 eye care professionals from 100 University of Cape Town Community The next issue of the Community Eye Health countries in Durban in October 2016. Eye Health Institute Journal will be on Neuro-ophthalmology. Over the course of three days, www.health.uct.ac.za or email It will include articles such as ‘Understanding there were over 60 sessions with 200 [email protected] vision and the brain’ and ‘Assessing the speakers, and over 250 poster presen- Lions Medical Training Centre neuro-ophthalmology patient’. This issue tations. If you couldn’t be there, you can Write to the Training Coordinator, will not be produced in paper format catch up on what you’ve missed: Lions Medical Training Centre, because of increasing costs in publication • View and download PowerPoint files of Lions SightFirst Eye Hospital, and distribution. It will be available online all the talks and presentations from PO Box 66576-00800, Nairobi, Kenya. at www.cehjournal.org. If you wish to www.iapb.org/10ga-presentations Tel: +254 20 418 32 39 receive an email with a link to download • Access IAPB’s Vision Atlas, which was Kilimanjaro Centre for Community the PDF copy, please send your email launched at the 10GA. It allows access Ophthalmology International address to [email protected]. to the latest data and evidence related Visit www.kcco.net or contact Genes The next paper issue, planned for the to avoidable blindness and sight loss: Mng’anga at [email protected] end of March 2017, will be on Continued http://atlas.iapb.org Professional Development. Thank you • Enjoy the photographs entered into the Subscriptions for your understanding. #StrongerTogether Photo Competition. www.cehjournal.org/subscribe The winners were announced at 10GA #StrongerTogether • For paper copies, email Anita Shah: and all entries can be viewed at [email protected] IAPB’s 10th http://photocomp.iapb.org General Assembly • To receive an alert when a new issue is (10GA), the published, email [email protected] premier global event discussing public Courses Visit us online: www.cehjournal.org health issues related to blindness and German Jordanian University www.facebook.com/CEHJournal/ visual impairment, brought together Email: [email protected] https://twitter.com/CEHJournal

Useful resources for ocular surface disease

Cochrane reviews Herpes simplex the Friedenwald lecture. Invest Opht Vis Blepharitis Wilhelmus KR. Antiviral treatment and Sci 2007;48(10):4390; 4391–4398. Lindsley K, Matsumura S, Hatef E, Akpek other therapeutic interventions for herpes Available online: https://www.ncbi.nlm. EK. Interventions for chronic blepharitis. simplex virus epithelial keratitis. Cochrane nih.gov/pmc/articles/PMC2886589/ Cochrane Database Syst Rev. 2012, 5: Database Syst Rev. 2015, 1:CD002898. Dry eyes CD005556. doi: 10.1002/14651858. doi: 10.1002/14651858.CD002898. Methodologies to diagnose and CD005556.pub2 pub5. monitor dry eye disease: report of the Pterygium Squamous cell carcinoma Diagnostic Methodology Subcommittee Clearfield E, Muthappan V, Wang X, Kuo Gichuhi S, Irlam JH. Interventions of the International Dry Eye Workshop IC. Conjunctival autograft for pterygium. for squamous cell carcinoma of the (2007). Ocul Surf. 2007;5(2):108–52. Cochrane Database Syst Rev. 2016, 2: conjunctiva in HIV-infected individuals. Available online: www.tearfilm.org/ CD011349. doi: 10.1002/14651858. Cochrane Database Syst Rev. 2013 28; dewsreport/ CD011349.pub2. 2:CD005643. doi: 10.1002/14651858. Baudouin C, Messmer EM, et al. Dry Eye CD005643.pub3. Revisiting the vicious circle of dry eye Ervin AM, Wojciechowski R, Schein O. disease: a focus on the pathophysiology Punctal occlusion for dry eye syndrome. Further reading of meibomian gland dysfunction. BJO Cochrane Database Syst Rev. 2010, 9: Ocular surface Online First, published on January 18, CD006775. doi: 10.1002/14651858. Gipson IK. The ocular surface: the 2016. Available online: http://tinyurl. CD006775.pub2. challenge to enable and protect vision: com/dry-eye-circle Community Eye Health Next issue JOURNAL Supported by:

The next issue of the Community Edmond J FitzGibbon www.eyewiki.aao.org Eye Health Journal is online and is about Neuro-ophthalmology

60 COMMUNITY EYE HEALTH JOURNAL | VOLUME 29 ISSUE 95 | 2016 ONLINE SUPPLEMENT Inequities in eye care in South Asia

impairment.1 A significant number of inequities. Overall, inequity or those not Thulasiraj Ravilla Executive Director- Aravind Eye Care people with avoidable visual loss are not served fall into a few broad categories: Systems being reached and served by the current eye care delivery system for a variety of Inequity due to socio- Inequities are often discovered and reasons including patient awareness economic factors: discussed around prevalence studies, and access to services. Thus, we need These relate to gender, literacy, which produces data relating to various to recognize that inequity in the eye marital status and wealth. They types of inequities. It sits in the space of care delivery system is a significant influence individuals on the level of periodic assessment and continues to cause of the remaining problem of empowerment, awareness, decision remain predominantly in the knowledge avoidable blindness. Therefore it is making position in the family, priority rather than action realm. Therefore relevant to look at how we currently for eye care and the extent of their there is a need for a paradigm shift in provide eye care and redesign it with an mobility. Several studies undertaken in how we think about and approach explicit focus on the goal of eliminating this region have shown a strong inequities in service. The goal of inequities. Such a health system design association between cataract “VISION 2020 - The Right to Sight” and should have inbuilt, on-going monitoring blindness and these factors. Studies in that of many organizations and govern- and processes for continuously identi- India have shown that women have a ments engaged in eye care is around fying and correcting inequities as they 20% higher chance of being blind than “eliminating avoidable blindness”. This occur, similar to what is done in clinical men; illiterate people are 3.7 times implicitly means that there are people audit and care process for reducing more likely to be blind than people who who are blind, but don’t need to be. This complications, , etc. It is time are literate; and unemployed people is true since proven interventions exist that this paradigm shift occurs in the are twice as likely to be blind than to treat or prevent the major causes of design of eye care services both at insti- employed people.2 Similarly studies in blindness or visual impairment. tutional and national level. In order to Bangladesh have shown that married Globally, it is reported that 39 million consider the redesign of eye care persons are almost half OR = 0.6 (0.4 people are blind and a further 246 delivery, it is important to have an – 0.9) as likely to be blind as single / million have moderate or severe visual understanding of the origin of these widowed persons.3

Inequity in eye care is one of the primary reasons for the continuing problem of avoidable blindness.

© The author/s and Community Eye Health Journal 2016. This is an Open Access COMMUNITY EYE HEALTH JOURNAL | VOLUME 29 ISSUE 95 | 2016 01 article distributed under the Creative Commons Attribution Non-Commercial License. Source: Current estimates of blindness in India; BJO 2005;89;257-260 Table – 1: Socio-demographic correlates of cataract blindness

Adjusted Odds Ratio Socio-demographic variables 95 % CI

Female 1.2 (1.2-1.3) Rural 1.2 (1.1-1.4) Illiterate 3.7 (2.7-5.2) Not Working 2.0 (1.8-2.2)

Location: countries preventable causes of this region and developing countries in blindness due to trachoma, vitamin-A general, the overarching focus has been Which same study? showed that deficiency and onchocerciasis still occur on cataract blindness and provision of those living in rural areas have a slightly in some poor communities and blindness cataract surgery. increased risk 1.2 (1.1 – 1.4) of due to treatable cataract is still the major While this has made an impact on blindness over those living in urban situa- cause. cataract blindness it has also led to a tions. clinical practice which is not The locational disadvantage that we Disease focus: comprehensive and people with other see at the individual level also plays out at In design of services and interventions, conditions, as simple as refractive unconsciously or sometimes due to the national level. In the more affluent or errors or with complex retinal purpose of funding (as in the World developed countries, the overall preva- pathologies have not received equitable lence of blindness is lower and those Bankfunded cataract programme in India), the focus tends to be on certain attention. Thus the biased preference to blind due to avoidable causes are much conditions. At individual or institutional some conditions has contributed in its less. This will reduce even further with the provider level such focus emerges often own way to inequity in the treatment advent of emerging treatment for condi- on account of economic considerations. and the management of other treatable tions like DR, ARMD and Glaucoma. In For instance, in most of the countries in conditions. contrast if we look at low income

S 02 COMMUNITY EYE HEALTH JOURNAL | VOLUME 29 ISSUE 95 | 2016 Table – 2: Technology & Quality

Sivaganga & Tirunelveli Surveys

Presenting Visual Acuity WHO Standard for Vision Outcomes Vision Category IOL (n=840) Non-IOL (n=989) Presenting Best Corrected

Normal (≥ 6/18) 77.3% 49.3% 80%+ 90%+ Impaired (<6/18-≥6/60) 18.0% 10.9% 15%+ 5%+ Blind (< 6/60) 4.7% 39.8% <5% <5%

Human Resource and fuelling inequity. When one looks at the the central concern. Such re-design Infrastructure: data around research and publication, it should happen at both operational care shows that over 92% of peer reviewed level and at the broader eco-system level. The scarcity of trained ophthalmic publications emanate from developed National policies should encourage local manpower is aggravated by the fact that countries, which account for 10% of evidence and research. Necessary they tend to be based in large urban global blindness. The developing capabilities will need to be developed and centres. This in turn dictates the location countries which account for over 90% of funding provided. Likewise regulations of eye hospitals and other eye care infra- blindness contributed to less than 8% of and policies should allow for easy access structure as well. An earlier assessment the publications.9,10 The local knowledge to cost-effective technologies as well as of distribution in India showed that over and evidence that emerge from research encourage local development. Focus 57% of the ophthalmologists were based are fundamental for effective design of should be to draw strategies and interven- in 56 cities which accounted for only 11% interventions and services. Conversely the tions to reach the unreached population of the population.4 Conscious of this lack of such evidence based design leads and thereby eliminate inequality in eye urban concentration of eye care services, to sub-optimal delivery of care and care. programmes emerged to reach out to the unintentionally results in inequities. rural areas essentially through eye When one looks at the macro design of References camps. However, the reach and impact of eye care in developing countries, one 1. Donatella Pascolini, Silvio Paolo Mariotti. Global this approach has been limited.5 sees that the overarching and in some estimates of visual impairment: 2010. Br J Ophthalmol Technology and Quality: instances, exclusive attention is given to (2011). hospital infrastructure. This has been 2. Murthy GVS, Gupta SK, Bachani D, Jose R, John N. Most technologies tend to be largely at secondary level, essentially to Current estimates of blindness in India.Br J developed in the West and are priced to offer treatment to those who present Ophthalmol. 2005 Mar;89(3):257–60. be relevant to those markets. Some themselves. This is a model that is 3. Polack S, Kuper H, Wadud Z, Fletcher A, Foster A. technologies, like an intra-ocular lens designed to be reactive to demand. This Quality of life and visual impairment from cataract in offer a dramatically better outcome and is quite appropriate to the western world, Satkhira district, Bangladesh. Br J Ophthalmol. 2008 quality of vision. The studies done in the where most people in need of eye care Aug;92(8):1026–30. 1990’s showed that presenting visual have the wherewithal and would seek it. 4. Kumar R. Ophthalmic manpower in India--need for a outcome in the aphakic eyes (non IOL) However, in developing countries the serious review. Int Ophthalmol. 1993 was categorised as blind (vision less than design has to be more proactive to Oct;17(5):269–75. 6/60) in 40% of the eyes, while in the stimulate demand. Significant emphasis 5. Fletcher A, Donoghue M, et al, Low uptake of eye same survey it showed that amongst the has to be on provision of appropriate eye care services in rural India, Archives of Ophthalmology pseudophakic eyes (with an IOL implant) care service at primary level recognizing Vol. 117 Oct. 1999 the blindness rate was as low as 4.7%.6, 7, the realities of the rural-urban divide, 6. Thulasiraj RD, Rahamathulla R, Saraswati A, Selvaraj 8 scarcity of skilled human resource and S, Ellwein LB. The Sivaganga eye survey: I. Blindness Such vast variations in the quality of access challenges. and cataract surgery. Ophthalmic Epidemiol. 2002 outcome affect demand and fuels the Paying capacity is another significant Dec;9(5):299–312. dynamics of inequity. In this instance the factor in developing countries where most 7. Thulasiraj RD, Reddy A, Selvaraj S, Munoz SR, Ellwein inequity of who got a better outcome was of the care is financed through out of LB. The Sivaganga eye survey: II. Outcomes of brought about by the high price of the pocket payments; unlike in the West cataract surgery. Ophthalmic Epidemiol. 2002 imported lenses. In the case of IOL, this where the State or near universal Dec;9(5):313–24. was addressed in India and Nepal, which insurance mechanism eliminates the 8. Nirmalan PK, Thulasiraj RD, Maneksha V, set up several IOL manufacturing affordability barrier. In hindsight, eye care Rahmathullah R, Ramakrishnan R, Padmavathi A, et factories and priced the IOLs to suit the systems in developing countries should al. A population based eye survey of older adults in economies of South Asian countries. have been built on a robust foundation of Tirunelveli district of south India: blindness, cataract Bringing about such equities has been primary eye care. The evidence for this is surgery, and visual outcomes. Br J Ophthalmol. 2002 possible only in a few instances like IOLs, just emerging and so is the establishment May;86(5):505–12. sutures and some pharmaceuticals. In of primary eye care. 9. Donatella Pascolini, Silvio Paolo Mariotti, Global many other areas, inequities in quality Conclusion & Suggestions: estimates of visual impairment: 2010, Br J driven by technology and their price Ophthalmol 2012;96:614e618. doi:10.1136/bjoph- continue to exist. Inequity should not continue to be a thalmol-2011-300539. Research and Evidence: by-product of population studies or a 10. Mandal K, Benson S, Fraser SG. The contribution to mere means of explaining the growing ophthalmic literature from different regions of the Though indirectly, research also seems backlog. It has to influence the design of world. Int Ophthalmol. 2004 May;25(3):181–4. to have played an unintended role in eye care services by making “inequity”

© The author/s and Community Eye Health Journal 2016. This is an Open Access COMMUNITY EYE HEALTH JOURNAL | VOLUME 29 ISSUE 95 | 2016 03 article distributed under the Creative Commons Attribution Non-Commercial License. GENDER BLINDNESS Trends in Gender and Blindness in India

Women tend to have a higher rate of blindness with lesser access to health care.

Dr GVS Murthy South Asia, the age-standardized adult 3.05% [95% CI:2.82-3.3] in 2006-2007 Vice-President, South, Public Health Foundation prevalence of blindness in women is 1.26 while in females it was 6.4% [95% CI: of India & Director, Indian Institute of Public times the prevalence among male 6.14-6.67] in 1999-2001 and 4.44% 9 Mr Hira Ballabh Pant adults . [95% CI: 4.19 – 4.70] in 2006-2007. India has been one of the countries The results show that there is a significant Mr Souvik Bandyopadhyay where efforts to strengthen the evidence- reduction in overall blindness between Dr Neena John base for blindness control has received 1999-2001 and 2006-2007 (X2- significant attention from policy planners 138.41; p < 0.001). The difference Among the many definitions one that and program managers. Over the past between males in the two rounds of the succinctly described equity is in a paper four decades a series of population-based surveys was also statistically significant published in 2003.1 The authors defined blindness and visual impairment surveys (X2-43.41; p < 0.001). The same was equity in health as the absence of have been undertaken in India, using also true for females (X2-103.79; p < systematic disparities in health or the different survey methods. This included 0.001). At the same time the difference major social determinants of health detailed eye examination surveys as well in the prevalence of blindness between between social groups who have different as rapid assessments. males and females was statistically signif- levels of underlying social advantages or To discern the temporal trends in icant both in 1999-2001 (X2-152.11; p disadvantages and which put people who relation to blindness and gender differen- < 0.001) and in 2006 – 2007 are already socially disadvantaged at a tials we have used data from two large (X2-57.96; p <0.001). The risk of further disadvantage with respect to their population-based surveys in India. One blindness in females was 1.41 times health.1 The underlying premise was that was conducted over the period higher compared to males in the urban health is essential to wellbeing and to 1999-2001 (detailed eye examination areas, while in rural areas the risk was overcome other effects of social disad- survey)7 and the other over the period 1.51 times higher. After adjusting for age, vantage.1 2006-2007 (rapid assessment of place of residence (urban/rural) and the One of the social determinants of blindness survey).8 Both surveys looked at year of the survey, it was observed that health that has been universally identified populations aged ≥ 50 years and defined females had a 1.76 times higher risk of is gender. Health inequalities between blindness based on presenting vision blindness compared to males. These men and women have been postulated to (visual acuity < 3/60 in both eyes). findings show that there is a clear cut result from societal structures, role A total of 108,609 individuals were gender disparity in the prevalence of expectations and the cultural context.2,3 It examined in the two surveys in India blindness in India. If one looks at the has been emphasized that women bear a (63,432 in 1999-2001 and 45,177 in percentage reduction in prevalence of disproportionate burden of health inequity 2006-2007). blindness, it was seen that there was a across the globe and face unique barriers The prevalence of blindness in 71% reduction in the overall prevalence in accessing health care.4 With respect to 1999-2001 was 5.36% [95% CI: 5.2- of blindness among those aged ≥50 eye care, women are more likely to have 5.5] while in 2006-2007, it was 3.82% years over a span of 8 years. Amongst higher rates of blindness and are less [95% CI: 3.64 – 4.0]. These results show males the reduction was 72.8% likely to access appropriate eye that there was a significant reduction in compared to 69.4% among females over services.5-8 Available evidence points to a the prevalence of blindness over this the same period. Cataract was the higher prevalence of blindness among period. The prevalence of blindness principal cause of blindness both in women compared to men in all regions of amongst males was 4.19% [95% CI: 1999-2001 and 2006-2007. It was the world after controlling for age as in 3.97-4.42] in 1999-2001 compared to observed that males had a 40% lower risk

S 04 COMMUNITY EYE HEALTH JOURNAL | VOLUME 29 ISSUE 95 | 2016 Table 1: Prevalence of blindness and association with gender in India

Characteristics 1999-2001 2006-2007

N (%) N (%) Prevalence [95%CI] Prevalence[95%CI]

No. examined 63,432 45,177 - -

No. males examined 30,013 - 20,331 -

No. female examined 33,419 - 24,846 -

Prevalence of Blindness 5.36% 5.18 – 5.53 3.82% 3.64 – 4.0

Prevalence of Blindness 4.19% 3.97 – 4.42 3.05 2.82 – 3.30 (Male)

Prevalence of Blindness 6.40% 6.14 – 6.67 4.43% 4.19 – 4.70 (Female)

of being cataract blind compared to access to cataract services in women incentives like a certificate of ‘women- females in both rounds of the surveys. have not been sufficient. In India where friendly institution’ etc., to operate on the This is an important observation as the overall status of women in society is females will help in enhancing access to cataract is a treatable cause of blindness poor, a gender focus is essential if gender women and thereby reduce the gender and an important determinant of equity is to be ensured, especially when differentials. The situation is likely to be avoidable blindness. The higher load of access to services is poor. Exclusive similar in countries of the South Asia cataract blindness in females over the 8 special incentives like higher region with similar economies to India. year period demonstrates inequity and reimbursement for females operated suggests that interventions to improve compared to males or for non-monetary

References

1. Braveman P, Gruskin S. Defining equity in health. J 5. Courtright P, Lewallen S. Why are we addressing gender 2008; 3(8): e2867.doi:10.1371/journal.pone.0002867 Epidemiol Community Health 2003; 57: 254-258. issues in vision loss? Community Eye Health J 2009; 22: 9. Stevens GA, White RA, Flaxman SR, Price H, Jonas JB et 2. Mathews D. How gender influences health inequalities. 17-19 al. Global prevalence of vision impairment and blindness: Nurs Times 2015; 111: 21-23. 6. Nirmalan PK, Padmavathi A, Thulasiraj RD. Sex inequal- Magnitude and temporal trends, 1990-2010. 3. Ostrowska A. Health inequalities – gender perspective. ities in cataract blindness burden and surgical services in Ophthalmology 2013; 120:2377 - 2384 Przegl Lek 2012; 69: 61-66. south India. Br J Ophthalmol 2008; 87: 847-49 4. Diaz Granados N, Pitzul KB, Dorado LM, Wang F, 7. Murthy GV, Gupta SK, Bachani D, Jose R, John N. Current McDermott S, Rondon MB et al. Monitoring gender equity estimates of blindness in India. British J Ophthalmol in health using gender-sensitive indicators: A cross- 2005; 89: 257–60 national study. J Womens Health (Larchmt) 2011; 20: 8. Neena J, Rachel J, Praveen V, Murthy GVS. Rapid 145-53 Assessment of Avoidable Blindness in India. PLoS ONE

© The author/s and Community Eye Health Journal 2016. This is an Open Access COMMUNITY EYE HEALTH JOURNAL | VOLUME 29 ISSUE 95 | 2016 05 article distributed under the Creative Commons Attribution Non-Commercial License. CATARACT SURGICAL Inequities in cataract surgical coverage in South Asia

Countries with lower GDP and per capita health expenditure tend to have a higher incidence of inequity in eye care

Countries with lower GDP and per capita health expenditure tend to have a higher incidence of inequity in eye care

Dr Rohit Khanna regions within the same country. Apart represented the entire country. Data from Director, Gullapeli Pratibha Rao from this, gender inequality in CSC has Bangladesh, Bhutan and Pakistan were Internations Centre for Advancement been reported from different low and from published sources, while data from of Rural Eye Care (GPRI CARE), middle income countries.3, 4 In this article Hyderabad Nepal was obtained from the RAAB repos- we review the CSC data from countries in itory. From other countries, regional data Dr GVS Murthy South-Asia (SA) and review inequities were available. Hence, extrapolation of Vice-President, South, Public Health between and within countries, especially these regional specific data to the entire Foundation of India & Director, related to gender. We also review the Indian Institute of Public Health. association between country wealth and country may not be appropriate. The CSC government health expenditure on CSC data (person and eyes) from these Introduction i.e. with Gross Domestic Product (GDP) countries (stratified by gender) is shown Recent estimates from the World of a country as well as per capita health in Tables 1 and 2. Health Organization (WHO) show that expenditure. In simple terms, GDP is the globally there are 285 visually impaired total monetary value of all goods and Results people of which 39 million are blind.1 services produced within a nation’s There is a wide variation in terms of Cataract is the major cause of blindness geographic borders over a specified people accessing cataract services. For and second leading cause for visual period of time. It is a measure of a visual acuity level of < 3/60, the range is impairment (VI).1 One of the important country's total economic activity. Health from 30.5% (Sindhudurg, India) to 92% parameters to measure the impact of expenditure is the sum of public and (Surat, India). At a CSC cut-off level of cataract services is the Cataract Surgical private health expenditure as a ratio of <6/60 and <6/18 the CSC is naturally Coverage (CSC). CSC is also one of the total population. lower than at <3/60. For visual acuity < indicators to monitor the progress of the 6/60, the range is 46.8% (Bangladesh) Universal Eye Health: Global Action Plan Methods 2 to 85.9% (Srisailam, India) and for visual 2014-19. CSC is defined as the South Asia encompasses Bangladesh, acuity level <6/18, it was 32.4% proportion of people or eyes with Bhutan, India, Maldives, Nepal Pakistan (Bangladesh) to 68% (Integrated Tribal cataract eligible for cataract surgery who and Sri Lanka. CSC data (stratified by Development Agency area of West and have received cataract surgery in at a gender) was obtained from published given point in time.’ It is one of the East Godavari, India) (Table 1). literature, the RAAB repository, as well as parameters or measures obtained from Similar trend was seen for CSC for by personal communications with the the Rapid Assessment of Avoidable eyes (Table 2). CSC for eyes with the Blindness (RAAB) or Rapid Assessment Principal Investigators (PI) of some same cut-off of visual acuity (<3/60; of Cataract Surgical Services (RACSS) studies. CSC data was available for all <6/60 and <6/18) was lower than for studies. It can also be obtained from countries except Maldives. Of the persons suggesting that most of these other population based studies (Table 1 remaining countries, gender specific data participants had unilateral cataract and 2). There is a gross variation in CSC was available for all. Data from surgery. across different countries as well as Bangladesh, Bhutan, Nepal and Pakistan

S 06 COMMUNITY EYE HEALTH JOURNAL | VOLUME 29 ISSUE 95 | 2016 All the countries had lower CSC for limited data was available in relation to • Countries with lower GDP and per females as compared to males (Table 1 literacy, socio-economic status and capita health expenditure, are likely to and 2). In countries like Bangladesh, urban-rural differences. Data from have more inequity Bhutan and Sri Lanka the difference was Bhutan showed that those residing in • We recommend that there is a need for high. A similar difference is seen for rural areas had a lower CSC as compared data to be collected from countries where other levels of visual acuity (<6/60 and to their urban counterparts5. Similarly there is none. In countries where there is <6/18). This suggests a significant data from Nepal (Gandaki Zone) showed only region-specific data, data is needed inequity in terms of females accessing that CSC was lower in illiterates6. A study to be representative of the whole country. services for cataract, especially in conducted in Sivaganga also showed Also data including key social determi- Bangladesh, Bhutan and Sri Lanka. that CSC was lower in older people, nants need to be collected. These countries also report a lower GDP those with no education as well as those • All countries should work towards and per capita health expenditure than residing in rural areas7. Pakistan National achieving the goal of Universal Eye Health the other countries in the region Blindness and VI survey also showed with at least 80% CSC for <3/60 visual suggesting that in poorer countries, lower CSC for illiterates, those residing in acuity category as well as ensuring that women are less likely to access eye care rural areas as well as older people, women, and those from the lower socio- services compared to economically richer suggesting gross inequity8. economic strata and rural areas have countries. Gender difference could be improved access to services. due to gender-defined social roles, which Conclusions and could be confounded by factors like Recommendations Limitations literacy, socioeconomic status as well as • There is gross inequity in terms of CSC One of the limitations of the data is urban-rural differences. It is likely that in countries of South Asia i.e. females that it is not representative of all the women in countries with lower CSC are have less access than males countries. We did not do any analysis to less educated, have other domestic • Inequity is also compounded due to see if the difference between gender was responsibilities and are not the main other social determinants like socio- significant or not. There was limited data earning member of the house, thus economic status, literacy, urban-rural available in terms of other social determi- having less access to eye care as well as difference etc. However, there is limited nants (socio-economic status, literacy, other health care services. However, evidence for it. urban-rural difference etc). Table 1: Cataract Surgical Coverage (by person), stratified by gender for countries in South Asia NA: Not available; ITDA: Integrated Tribal Development Agency; Personal communication: ^; RAAB Repository:@; Population Based Studies:# *SOURCE: http://data.worldbank.org/indicator/SH.XPD.PCAP?page=3; ** SOURCE: http://data.un.org/CountryProfile.aspx?crName=MYANMAR

Per capita GDP at health Country Location Year Person Person Person Person Person Person Person Person Person time of expend- survey* iture**

Less than 3/60 Less than 6/60 Less than 6/18

Male Female Total Males Females Total Males Females Total

India^ 15 districts $1.23 2007 NA NA 82.3 NA NA 66 NA NA NA $43 in 16 trillion states

India Nandu- $1.36 2009 NA NA NA NA NA NA NA NA NA $48 rbar9 trillion

India Kolar10 $1.83 $66 2011 84.6 79.7 81.7 75.7 69.8 72.2 65.6 63.1 64.1 trillion

India Sindh- $1.17 2010 32 28.4 30.5 NA NA NA NA NA NA $59 udrug11 trillion

India Siva- $466.86 1999 NA NA NA 80.9 75.2 77.5 NA NA NA $18 ganga7 billion

India^ ITDA- Kham- $1.36 mam & 2009 88.3 87.8 88 79.6 78.8 79.1 62.4 67.2 65.1 $48 trillion War- ngal

India^ ITDA- East Godav- $1.36 ari & 2009 86.2 83.8 84.6 76.5 78.6 77.8 65.1 69.8 68 $48 trillion West Godav- ari

© The author/s and Community Eye Health Journal 2016. This is an Open Access COMMUNITY EYE HEALTH JOURNAL | VOLUME 29 ISSUE 95 | 2016 07 article distributed under the Creative Commons Attribution Non-Commercial License. Per capita GDP at health Country Location Year Person Person Person Person Person Person Person Person Person time of expend- survey* iture** Less than 3/60 Less than 6/60 Less than 6/18

Male Female Total Males Females Total Males Females Total

India^ ITDA- $1.36 Srisail- 2009 95.7 88.1 91.5 90.1 82.6 85.9 68.9 63.6 65.9 trillion $48 am

Tribal region in $1.83 India@ 2011 95.7 89.6 92 88.4 79.2 82.7 60.1 51.6 54.9 $66 Surat trillion Gujarat

Satkhira12 $69.44 Bangladesh 2005 63.6 59 60.9 57.9 55.1 56.3 34.5 36.4 35.6 $12 billion

8 $115.27 Bangladesh 2010 76.6 64.3 69.3 51.1 43.9 46.8 35.1 30.5 32.4 $23 districts13 billion

Bhutan Whole $818.86 2005 81.8 85 83.3 82.6 72 77 60 50 54.7 $66 [Urban] country5 billlon

Bhutan Whole $818.86 2005 75 60 67.4 60.7 43.1 51.2 41.4 27.3 34 $66 [Rural] country billlon

Bhutan Whole 2005 $818.86 77.8 67.7 72.7 67.1 51.1 58.6 46.3 33.3 39.4 $66 [Both] country billlon

Srilanka [40 yrs $28.27 Kandy14 2006 90.6 76.7 82.7 80 74.2 76.8 47.3 41.8 41.9 $58 above and billlon bleow]#

Whole 2008- $12.54 Nepal@ 88 83 85 72 69 70 56 54 55 $29 country 2010 billlon

Whole 2003- $83.24 Pakistan# 79.6 74.9 77.1 70.1 68.4 69.3 44.6 42.8 43.7 $16 country8 2005 billlon

Table 2: Cataract Surgical Coverage (by eyes), stratified by gender NA: Not available; ITDA: Integrated Tribal Development Agency; Personal communication: ^; RAAB Repository:@; Population Based Studies:# *SOURCE: http://data.worldbank.org/indicator/SH.XPD.PCAP?page=3; ** SOURCE: http://data.un.org/CountryProfile.aspx?crName=MYANMAR

Per capita GDP at health Country Location Year Eyes Eyes Eyes Eyes Eyes Eyes Eyes Eyes Eyes time of expend- survey* iture**

Less than 3/60 Less than 6/60 Less than 6/18

Males Females Total Males Female Total Males Females Total

India^ 15 districts $1.23 2007 NA NA 62.9 NA NA 47.7 NA NA NA $43 in 16 trillion states

India Nandu- $1.36 2009 NA NA NA NA NA 9.4 NA NA NA $48 rbar9 trillion

India Kolar10 $1.83 $66 2011 72.1 67.8 69.6 60 57.3 58.4 50 48.6 49.2 trillion

India Sindh- $1.17 2010 NA NA NA NA NA NA NA NA NA $59 udrug11 trillion

India Siva- $466.86 1999 NA NA NA NA NA NA NA NA NA $18 ganga7 billion

S 08 COMMUNITY EYE HEALTH JOURNAL | VOLUME 29 ISSUE 95 | 2016 Per capita GDP at health Country Location Year Eyes Eyes Eyes Eyes Eyes Eyes Eyes Eyes Eyes time of expend- survey* iture**

Less than 3/60 Less than 6/60 Less than 6/18

Males Females Total Males Female Total Males Females Total

India^ ITDA- Kham- $1.36 mam & 2009 71.2 68.5 69.6 61.4 61.4 61.4 45.5 50.9 48.6 $48 trillion War- ngal

India^ ITDA- East Godav- $1.36 ari & 2009 68.8 65.1 66.5 60.1 57.3 58.4 41.8 42.4 42 $48 trillion West Godav- ari

India^ ITDA- $1.36 Srisail- 2009 75.2 72.3 73.6 68 65.2 66.5 49.2 45.4 47.1 trillion $48 am

Tribal region in $1.83 India@ 2011 89 82.2 84.9 77.7 69.1 72.5 48.1 42.1 44.5 $66 Surat trillion Gujarat

Satkhira12 $69.44 Bangladesh 2005 34.6 34.9 34.8 30.9 30.4 30.6 17.4 18.7 18.1 $12 billion

8 $115.27 Bangladesh 2010 61.5 49.7 55.1 38.2 30.9 33.9 20.1 21.3 22.9 $23 districts13 billion

Bhutan Whole $818.86 2005 65.1 69.8 67.5 61.2 57.1 59 40.6 38.6 39.5 $66 [Urban] country5 billlon

Bhutan Whole $818.86 2005 59.7 42.6 50.9 44.3 31.4 37.6 27.9 19.5 23.5 $66 [Rural] country billlon

Bhutan Whole 2005 $818.86 61.5 51.3 56.3 49 38.9 43.7 31.3 24.8 27.9 $66 [Both] country billlon

Srilanka [40 yrs $28.27 Kandy14 2006 67.2 63.6 65.2 60 60.5 60.3 35.1 33.1 34 $58 above and billlon bleow]#

2008- $12.54 Nepal@ country 68.9 65.7 67.1 59.5 56.6 57.9 40 38.8 39.4 $29 2010 billlon

2003- $83.24 Pakistan# National8 64.5 58.4 61.4 54.5 50.0 52.2 42.8 36.6 40.7 $16 2005 billlon References

1. Pascolini D, Mariotti SP. Global estimates of visual impairment: 2010. The British journal of ophthal- 9. Dhake PV, Dole K, Khandekar R, Deshpande M. Prevalence and causes of avoidable blindness and mology 2012; 96(5): 614-8. severe visual impairment in a tribal district of Maharashtra, India. Oman J Ophthalmol 2011; 4(3): 2. WHO. Universal eye health. A global action plan 2014-2019. WHO, Geneva 2013: 1-28. 129-34. 3. Lewallen S, Courtright P. Gender and use of cataract surgical services in developing countries. Bulletin 10. Bettadapura GS, Donthi K, Datti NP, Ranganath BG, Ramaswamy SB, Jayaram TS. Assessment of of the World Health Organization 2002; 80(4): 300-3. avoidable blindness using the rapid assessment of avoidable blindness methodology. North American 4. Lewallen S, Mousa A, Bassett K, Courtright P. Cataract surgical coverage remains lower in women. Br J journal of medical sciences 2012; 4(9): 389-93. Ophthalmol 2009; 93(3): 295-8. 11. Patil S, Gogate P, Vora S, et al. Prevalence, causes of blindness, visual impairment and cataract surgical 5. Lepcha NT, Chettri CK, Getshen K, et al. Rapid assessment of avoidable blindness in Bhutan. services in Sindhudurg district on the western coastal strip of India. Indian journal of ophthalmology Ophthalmic Epidemiol 2013; 20(4): 212-9. 2014; 62(2): 240-5. 6. Sapkota YD. Prevalence of blindness and cataract surgery in Gandaki Zone, Nepal. British Journal of 12. Wadud Z. Rapid assessment of avoidable blindness and needs assessment of cataract surgical services Ophthalmology 2006; 90(4): 411-6. in Satkhira District, Bangladesh. British Journal of Ophthalmology 2006; 90(10): 1225-9. 7. Thulasiraj RD, Rahamathulla R, Saraswati A, Selvaraj S, Ellwein LB. The Sivaganga eye survey: I. 13. Muhit M, Wadud Z, Islam J, et al. Generating Evidence for Program Planning: Rapid Assessment of Blindness and cataract surgery. Ophthalmic Epidemiology 2002; 9(5): 299-312. Avoidable Blindness in Bangladesh. Ophthalmic Epidemiol 2016; 23(3): 176-84. 8. Jadoon Z, Shah SP, Bourne R, et al. Cataract prevalence, cataract surgical coverage and barriers to 14. Edussuriya K, Sennanayake S, Senaratne T, et al. The Prevalence and Causes of Visual Impairment in uptake of cataract surgical services in Pakistan: the Pakistan National Blindness and Visual Impairment Central Sri Lanka. Ophthalmology 2009; 116(1): 52-6. Survey. Br J Ophthalmol 2007; 91(10): 1269-73.

© The author/s and Community Eye Health Journal 2016. This is an Open Access COMMUNITY EYE HEALTH JOURNAL | VOLUME 29 ISSUE 95 | 2016 09 article distributed under the Creative Commons Attribution Non-Commercial License. The core strategy of the initiative is to use local human resources to strengthen

REACHING THE UNREACHED IN SUNDERBANS

Dr Asim Sil indicate poor utilization of public facilities. higher proportion of cataract blindness Medical Director, Vivekananda Mission Major part of the Indian Sunderbans and lowercataract surgical coverage than Ashram Netra Niramay Niketan. belongs to South 24 Parganas District men. where 83% and 14% cataract Untreated cataract is the major cause are done by NGO and Government of visual impairment at all levels Background Hospitals respectively. (VA<3/60, VA<6/60 and VA<6/18 – best corrected VA or pinhole) of visual The Sunderbans is situated in the Ganges Sunderban’s Eye Health acuity. Overall, 1.2% of the total delta, bordering the Bay of Bengal, with a population is bilaterally blind due to large component being in Bangladesh. Service Strengthening Project cataract, and another 0.9% are blind in The Indian part, which is in West Bengal one eye. Women are disproportionately State has 106 islands and 24 (Parganas) Standard Chartered Bank, under the affected by cataract blindness both bilat- districts. People live on 52 islands and the “Seeing is Believing” initiative is erally (1.5% vs 1.0%) and unilaterally adjacent mainland, with the uninhabited supporting to implement the (1.0% vs 0.8%). areas being mainly mangrove forests. “Sunderbans Eye Health Service In total, nearly 11% of eyes in the The Sunderbans is a very challenging Strengthening Project”. The objective of sample were affected by cataract at areas to live in, and the area is prone to the five year project, 2013-2018, is to VA<6/18 or less. This was greater among natural disasters such as typhoons and contribute to the elimination of avoidable women (12.4%) than men (9.4%). Among flooding. The population of 19 blocks of blindness in the area. people aged over 50, this proportion of Sunderban was estimated at 4.7 million cataract eyes increased to 18.5%. in 2011. It is an area of extreme Baseline Study on Eye The commonest reason given for not and ill health exacerbated by access diffi- Health in Sunderban undergoing cataract surgery was ‘no felt culties. Almost half of the population need’ (30.8%), with underlying reasons (47%) are historically marginalized groups In order to assess eye health status being ‘old age’, ‘normal vision in other such as Scheduled Castes and Tribes. and health seeking behavior, a population eye’ and ‘other competing priorities’. More than 40% of households live below based survey among individuals aged 40 Amongst men, ‘cost of surgery’ was the the poverty line and 13% are officially years and above was conducted as the next most common reason while women declared as the “poorest of the poor”. initial step. The survey identified 3,388 reported ‘lack of awareness about The main occupations are farming and eligible individuals living in 19 blocks services.’ fishing. Cultivation depends on rain water 2,854 (84.2%) of whom were examined. 75.2% of the sample had as the river water has high salinity, and There was higher non response amongst but less than half (46.2%) had access to over half of those engaged in farming are males due to occupational migration.The near correction. More than half (54%) landless laborers. To protect fields from prevalence of blindness using the World were not even aware that they could salty river water high embankments are Health Organization definition (presenting benefit from spectacles. Financial reasons built around cultivated land. VA<3/60 in the better eye) was 1.9% were the most commonly reported barrier Out migration of those of working age (2.1% among those aged 50 years and for not getting a check-up for glasses to cities and towns is very high and the above). Using the Indian (NPCB) definition (51.4%). Broken or lost glasses were the worst social problem is human trafficking. (presenting VA<6/60 in the better eye) most common reason (38.9%) for discon- Areas which have good infrastructure the prevalence was 6.7% (10.0% tinuation of spectacle use. People are which connect communities to the amongst 50+). The prevalence of willing to pay INR 30 for check up and INR mainland have higher socioeconomic blindness was higher among females 100 for the glasses.5,6 status than island communities where (8.0%) than males (5.6%).The prevalence transport relies on the waterways. of severe visual impairment (presenting Baseline Study on Eye As survival is the main issue, education VA<6/60 – 3/60) was 4.8% (7.2% among Health in Sunderban and health are not given high priority. For the 50+). example, despite high primary school The prevalence of blindness in Sightsavers is partnering with three eye enrolment, there is very high Sunderbans was 1.88% (NPCB definition) care institutions (Southern Health non-attendance in upper primary levels.1 which is almost 40% higher than the Improvement Samity; Sunderban Social Availability of health care facilities varies national average (1.36%).4 Amongst Development Centre and Vivekananda from less than one to five per 100,000 those aged 40+, 83.8%of blindness was Mission Ashram, Chandi Branch) located population,3 and the morbidity rate is due to cataract, 12.0% due to refractive near Sunderbans who are already higher in Sunderban than the state errors and 4.2% due to other causes. The providing services in the region. The average. Children are three times more commonest cause of blindness among Government Health Department is prone to respiratory diseases and commu- the 50+ population was cataract (83.4%) another partner. Both the facilities of nicable diseases are highly prevalent. being higher than the 77.5% reported Vivekananda Mission Ashram Netra People who collect honey in the forests or from a RAAB survey (2007) in West Niramay Niketan are used as the training catch fish are under constant threat of Bengal.4 Cataract surgical coverage was and referral centre. attacks by animals and snake bites.2 less than 50%, i.e. a large proportion of NGO hospitals are the major service cataract-blind are still unreached. Women Human resource providers but may also Sunderban had a higher prevalence of blindness, development

S 10S10 COMMUNITY EYE HEALTH JOURNAL | VOLUME 29 ISSUE 95 | 2016 The core strategy of the initiative is to use local human resources to strengthen

The core strategy of the initiative is to use and proper referral. big challenge. The current strategy is to REACHING THE UNREACHED IN local human resources to strengthen the Accredited Social Health Activists undertake continuous training of VTs to fill eye care service because health profes- (ASHAs) and Auxiliary Nurse Midwives the gaps, and advocacy to change institu- sionals from outside are not likely to stay (ANMs) are workers at the grassroots tional policies in favour of retention. SUNDERBANS in such a difficult location. Local young level. 930 health workers of these cadres Refresher courses are taking place to people have been trained as Vision are being trained in identification of improve quality of services. Technicians (VT) and Community Health cataract and to create awareness. Making Vision Centres sustainable is Workers (CHW). Finding children with cataract currently the toughest challenge. The continues to be challenging in performance of each centre has been Establishing Vision Centres Sunderban. A Higher proportion of boys systematically analyzed and attention has with cataract was found and this could be been given to strengthening the weaker Seventeen Vision Centres have been due to two reasons. One is the health ones. Emphasis is being placed on established and are managed by trained seeking behavior of the community and increasing uptake of services through VTs who perform refraction, recognize traumatic cataracts are greater more better services, increasing the number of cataract and other conditions, referring among boys. spectacles sold, and IT based monitoring of cases to the NGO or Government activities. Continuation of service activities hospitals. Spectacles are provided at an beyond the project period mostly depends affordable or subsidized cost. Each centre Challenges and way on the sustainability of these units. has an optical dispensing unit which is forward Planning an eye care project in a supported by an optical laboratory at the Gaining the trust of the community relatively inaccessible geographic region base hospital. All these are stand-alone was an initial challenge as some had had needs special consideration. An effort centres for eye care only. Two vision unpleasant experiences from other eye should be made to select and train workers centres are being established within care providers. The quality and the price from the same region. While budgeting, a government PHCs. of spectacles, and poor quality of clinical significant amount should be allotted for services and cataract surgery were the transport. This kind of project can never be Awareness generation main issues. a remotely managed one. Active partici- activities Identification of cataract among pation of first and second tiers of children is another challenge. Efforts are Trained CHWs and VTs constantly leadership is very essential for monitoring, being undertaken to screen families motivating field staff, deepening the engage in a range of awareness gener- where hereditary cataract has been ation activities using IEC materials in relationship with the community and detected. over all sustainability. group meetings and one-to-one Retaining trained staff continues to be a counseling. Direct Service Delivery The hospitals undertake outreach eye screening camps in interior locations in Sunderbans. The CHWs and VTs also conduct eye examination of children in schools near the vision centres where they provide free spectacles. People who need cataract surgery are taken to the base hospital and the follow up is arranged at the vision centre. This entire service is offered free of cost to patients. Strengthening the existing health system In Sunderbans there are two Sub-Division Government hospitals with facilities for eye surgery. Efforts are underway to improve the volume and quality of cataract surgery through training. The government sub-divisional hospitals in Sunderbans are poorly managed, conducting less than 100 cataract surgeries annually. The project plans a facility survey, to enhance capacity, training on protocol and cataract management and thus hold hands to improve services locally. Rural Medical Practitioners are important health providers in remote areas and there are plans to train 2,520 Sunderbans is an area of extreme poverty of these practitioners in primary eye care and ill health exacerbated by access difficulties

© The author/s and Community Eye Health Journal 2016. © This The is author/s an Open and Access Community article distributedEye Health under Journal the 2016. Creative This is an Open Access COM COMMUNITY EYE HEALTH JOURNAL | VOLUME 29 ISSUE 95 | 2016 S11 articleCommons distributed Attribution under Non-Commercial the Creative Commons License. Attribution Non-Commercial License. Progress against planned output for 01 October 2015 to 31 March 2016:

Output type Target Planned Outputs Actual outputs to date Variance%

M F Total M F Total PATIENTS Surgeries (per eye)

Cataract 27,000 5,233 5,567 10,800 5,751 6,045 11,796 109 surgery: adults

Good outcome 80% 4,606 4,868 9474 4,415 4,155 8,570 90 VA >6/18

Cataract surgery: 200 39 41 80 29 13 42 53 children

Screening

School screening 457,800 (1,308 114,456 128,871 243,327 98,676 111,543 210,219 86 children schools)

Adult RE 330,000 56,663 59,887 116,550 59,770 61,076 120,846 104 screening

Refraction

Refractions/ prescriptions 87,000 18,037 17,563 35,600 31,487 30,781 62,268 175 (adults):

Spectacles prescribed 43,200 8,600 9,128 17,728 15,599 16,160 31,759 179 (adults):

Free spectacles 3,844 689 785 1,474 757 848 1,605 109 supplied (adults):

Spectacles supplied 9,156 1,541 1,787 3,328 1,224 1,325 2,549 77 (children):

References

1. Human Development Report South 24 Parganas 2009. Published by Development and Planning Department, Govt. of West Bengal 2. Health care in the Sunderbans(India), challenges and plan for a better future; BarunKanjilal et al, Future Health System Research Programme, January, 2010. 3. Spatial Inequality in Health Care Infrastructure in Sunderban, West Bengal, India. Dipanwita De, International Research Journal of Social Sciences, Vol. 3 (12) 15 -22, December (2014). 4. Rapid Assessment of Avoidable Blindness – India, Report 2006 – 2007, National Program for Control of Blindness, Ministry of Health and Family Welfare, Govt. of India. 5. Proceedings of Esri User Conference on July 20–24, 2015 in San Diego, California by Emma Jolley. 6. Communication from Sightsavers.

S12S 12 COMMUNITY EYE HEALTH JOURNAL | VOLUME 29 ISSUE 95 | 2016 LETTER TO THE EDITOR

Emel Hospital, Syria

The civil war in Syria is arguably the worst humanitarian catastrophe since the Second World War. According to recent sources, over 250,000 have been killed, the same number wounded or missing and over half of the country’s population of 22 million having been displaced from their homes, with 3.8 million being made refugees.

Aleppo, in the north of the country, has received far more than its fair share of mass destruction and has been the worst hit city in the civil war. It has seven remaining functioning hospitals, but supplies and medical care is dwindling. Several hospitals have been directly hit by bombing on more than one occasion and refugees head out of the city for medical treatment. One of the hospitals providing emergency care, including eye care, is Emil Hospital – located 70km from the centre of Aleppo. Emel Hospital provides most of the surgical services in the area, treating many severe injuries resulting from the violence. It is one of 42 similar field hospitals inside Syria, 65% of which have suffered attacks.

The medical director of Emel Hospital is Ahmed Hassan Batal, a paediatric ophthalmologist from Saudi Arabia. Since the conflict began, he and his team of 10 doctors and 20 nurses have performed more than 9,000 complex surgical procedures on patients with horrific injuries caused by the violence. The medical facilities at Emel are barely adequate: much of the equipment is secondhand, having been donated from several sources, and there is a huge shortage of drugs and dressings.

Thankfully, Emel Hospital has, at the time of writing, been spared the bombing that many other hospitals have endured. A neighbouring hospital, only one kilometer away, has been bombed twice. One can only imagine the anxieties of those working at Emel that it may suffer the same fate. However, Dr Batal describes the morale of the medical staff as remaining “very good”. He stresses the fact that staff members ignore the risks of working at the hospital for the benefit of all patients, whatever their beliefs and politics may be. Dr Batal himself has committed to working at the hospital until the conflict ends.

Despite the daily challenges of working at Emel, Dr Batel has remained an active member of the Examinations Committee of the International Council of Ophthalmology (ICO) – an international organisation which represents and serves professional associations of ophthalmologists. In his role, Dr Batal reviews all ICO examination papers, sets appropriate questions, and ensures the validity, accuracy and standardisation of each examination paper. He has also agreed to pay the examination fees of all Syrian ophthalmologists wishing to take ICO examinations and has pledged to continue doing so until the conflict in Syria ends – thereby ensuring that Syrian ophthalmologists are not left behind in their professional development as a result of the

COMMUNITY EYE HEALTH JOURNAL | VOLUME 29 ISSUE 95 | 2016 S 13 conflict. As a result, 62 Syrian ophthalmologists have already sat the ICO examinations in Damascus and many more wish to take the examinations in 2017.

I would like to thank Dr Batal on behalf of the ICO and the ICO Examinations Committee for his kindness and humanity. He is an example to us all.

Simon Keightley FRCS FRCOphth Director for Examinations International Council of Ophthalmology

Emel Hospital is in need of support. If you can help, please contact Simon Keightley via email: [email protected]

Dr Ahmed Batal (left) at the entrance to Emel Field Dr Batal with patient with bilateral lower limb Hospital. In the centre is Dr Hamedy Osman, the amputations founder of the hospital. Next to him is Dr Nabil Mureden, a volunteer surgeon and chairman of the Italian-Syrian community in Italy

COMMUNITY EYE HEALTH JOURNAL | VOLUME 29 ISSUE 95 | 2016 S 14

Dr Batal with a victim of the conflict Operating theatre following surgery involving a severe trauma case

Child victim of the conflict at Emel Hospital Severe left eye injury following trauma

COMMUNITY EYE HEALTH JOURNAL | VOLUME 29 ISSUE 95 | 2016 S 15